^     THE      \ 
a   LIBRAR8ES  % 


HIALTH 
SCIESCB8 
T.IBKASCf 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/roentgendiagnosiOOgeor 


^^  ■  r 


/ 


r 


ynsMK^     \  ^  I  ^ 


«::yuoAu)'?*v.K^.rrv^, 


RESECTED  PORTION  OF  SIGMOID 


THE  ROENTGEN 
DIAGNOSIS    OF    SURGICAL    LESIONS 

of  the 

GASTRO-INTESTINAL  TRACT 


BY 


ARIAL  W.  GEORGE,  M.D. 

Assistant  Professor  of  the  Department  of  Roentgenology,  Tufts  College  Medical  School;  Con- 
sulting Roentgenologist  to  the  Carney  Hospital ;  Boston  Dispensary  and  the 
Forsyth  Dental  Infirmary;  Fellow  of  the  Massachusetts 
Medical  Society;  Member  of  the  American 
Roentgen  Ray  Society 

AND 

RALPH  D.  LEONARD,  A.B.,  M.D. 

Assistant  in  the  Roentgen  Department  of  the  Boston  City  Hospital;  Instructor  in  Roentgenology 
at  Tufts  College  Medical  School;  Fellow  of  the  Massachusetts  Medical  Society 


THREE  HUNDRED  AND  SIX  PAGES 
Including  Seven  Three-color  Illustrations 
Eighteen  Artist's  Drawings,  Three  Hundred 
and  Forty-three  Roentgen    Plate  Reproductions 


BOSTON 
THE   COLONIAL  MEDICAL  PRESS 

NINETEEN    HUNDRED    AND    FIFTEEN 
ALL   RIGHTS   RESERVED 


Copyright,  1915,  by 

THE    COLONIAL    MEDICAL    PRESS 

All  rights  reserved,  including  that  of  translation 

into  foreign  languages,  including 

the  Scandinavian 


To 

FRANCIS    H.    WILLIAMS,    M.D. 

BOSTON 

IN   RECOGNITION   OF   THE   AID    WHICH 

HE  HAS  GIVEN  TO  THE  SUBJECT 

OP   ROENTGENOLOGY 


PREFACE 

The  purpose  of  this  work  is  to  demonstrate  what  one  Roentgen  chnic  has  accompUshed 
toward  estabUshing  a  method  for  exact  diagnosis  in  the  common  surgical  lesions  of  the  gastro- 
intestinal tract.  We  are  presenting  the  typical  Roentgen  pictures  of  normal  and  pathological 
gastro-intestinal  conditions.  The  text  has  been  kept  as  brief  as  possible,  and  endeavor  has 
been  made  to  use  the  nomenclature  as  adopted  by  the  American  Roentgen  Ray  Society.  (See 
page  278  for  these  terms.) 

It  is  hoped  that  this  work  will  be  of  value  not  alone  to  the  Roentgenologist,  but  to  the 
general  practitioner  and  surgeon.  To  the  physician  this  book  will  mean  a  greater  familiarity 
with  the  possibilities  of  Roentgen  diagnosis  and  a  better  appreciation  of  the  real  value  of 
Roentgen  evidence.  However,  we  shall  rest  content  if,  with  any  measure  of  success,  prog- 
ress has  been  made  toward  the  true  classification  and  standardization  of  the  varied  and 
confusing  Roentgen  observations. 

The  cases  on  which  this  study  has  been  based,  with  the  exception  of  four  gastric  ulcers, 
are  all  taken  from  our  private  clinic.  The  ultimate  diagnosis  in  each  case  has  been  made 
by  operation,  autopsy,  or  unmistakable  chnical  course.  Furthermore,  the  cases  are  con- 
sidered purely  from  the  Roentgen  point  of  view. 

We  have  often  found  the  clinical  evidence  to  be  so  superficial  and  inaccm-ate  that  we 
have  practically  eliminated,  from  the  text,  the  whole  clinical  story.  Again,  it  is  not  within 
the  scope  of  this  book  to  enter  to  any  extent  into  the  purely  technical  details  involved 
in  the  general  practice  of  Roentgenology. 

Careful  consideration  has  been  given  to  the  method  of  reproducing  the  Roentgen  plates. 
The  positive  half-tone  seems  to  most  accurately  simulate  the  original.  All  reproductions 
have  been  made  from  reduced  photographs  of  the  Roentgen  plate.  Rarely  do  they  equal 
the  briUiancy  of  the  original,  but  in  not  a  single  instance  has  there  been  any  artificial 
tampering  to  improve  the  appearance  of  the  reproduction. 

All  artist's  plates  are  from  drawings  made  at  the  time  of  operation  by  Miss  Blair  of 
the  Department  of  Surgical  Pathology,  Harvard  Medical  School,  to  whom  the  writers  are 
indebted.  These  drawings  are  at  least  diagrammaticaUj^  correct  and  have  been  approved  in 
each  case  hj  the  operating  surgeon. 

Finally,  we  wish  to  express  our  gratitude  to  Doctors  C.  L.  Scudder,  E.  A.  Locke, 
J.  W.  Dewis,  and  George  Carroll  Smith  of  Boston,  also  to  Dr.  Isaac  Gerber  of  Providence, 
R.  I.,  for  their  enthusiasm  and  material  assistance  in  carrying  out  this  work. 

ARIAL  W.  GEORGE 
RALPH  D.  LEONARD 


43  Bay  State  Road,  Boston. 


TABLE   OF  CONTENTS 

Section        I.  NORMAL  STOMACH. 

Indirect  Method  —  Direct  Method  —  Meals  —  Apparatus  —  General 
Routine  —  Normal  Stomach. 

Section      II.  GASTRIC  ULCER. 

Definition  —  Technique  —  Normal  Gastric  Shadow  —  Variations  from 
the  Normal  —  Positive  Signs  of  Ulcer  —  Presumptive  Signs  of  Ulcer. 

Section     III.  GASTRIC  NEW  GROWTH. 

Classification  —  Value  of  the  Roentgen  Ray  in  Diagnosis  and  Prog- 
nosis —  Early  Carcinoma  —  Advanced  Carcinoma  with  Symptoms  — 
and  Without  Symptoms  —  Value  of  the  Negative  Plate. 

Section     IV.  DUODENUM. 

Definition  —  Pathology  —  Possibility  of  a  Positive  Diagnosis  —  "Seven 
Propositions  "  —  Serial  Plates  —  Presumptive  Evidence  —  Value  of 
Roentgenoscope. 

Section       V.  GALL-BLADDER. 

Percentage  of  Stones  which  Show  —  Technique  —  Preparation  and 
Position  of  Patient,  Tubes,  Plates,  Screens,  Stereoscopic  Plates  — 
Demonstration  of  Diseased  Gail-Bladder  —  Adhesions. 

Section     VI.  SMALL  INTESTINE. 

Jejunum  —  Ileum  —  Normal  Roentgen  Picture  —  Malposition  —  Func- 
tional and  Organic  Disturbances. 

Section    VII.  APPENDIX. 

Meals  —  Technique  —  Pathological  Appendices. 

Section  VIII.  LARGE  INTESTINE. 

Method  of  Study  —  Opaque  Meal  and  Enema  —  Normal  Appearance 
—  Chronic  Constipation  —  New  Growth  —  Malformation  and  Malposi- 
tion —  Adhesions  —  Colitis. 

Section     IX.  DIVERTICULITIS. 


LIST  OF  ILLUSTRATIONS 


NORMAL  STOMACH 

Fig.  No.  Page  No. 

1  Key  plate .  ■ 7 

2  Normal  stomach.     Variation   ot  the   stomach   and 

duodenum 

3  Normal  stomach.     Lateral  view 

4  Normal  stomach.     Lateral  view 

5  Normal  stomach 

6  Same  case  as  Fig.  5.     Lateral  view 

7  Same  case  as  Fig.  5  showing  pressure  on  stomach . .  . 

8  Normal  stomach 

9  Same  case  as  Fig.  8.     Upright  position 

10  Same  case  as  Fig.  8.     Six  hours  after  the  bismuth 

meal 

11  Same  case  as  Fig.  8.     Twenty-four  houi's  after  the 

bismuth  meal 

12  Normal  stomach 

13  Same  case  as  Fig.  12.     Upright  position 

14  Normal  stomach.     Ptosis  and  dilatation 

15  Same  case  as  Fig.  14.     Upright  position 

16  Normal  stomach.     Ptosis 

17  Same  case  as  Fig.  16.     Six  months  later 

18  Same  case  as  Fig.  17.     Six  hours  after  bismuth  meal 

19  Normal  stomach.     Dilatation  and  ptosis 

20  Same  case  as  Fig.  19.     Upright  position 

21  Dilated  stomach 

22  Same  case  as  Fig.  21 

23  Normal  stomach 

24  Same  case  as  Fig.  23.     Upright  position 

25  Normal  stomach 

26  Same  case  as  Fig.  25 

27  Normal  stomach 

28  Normal  stomach 

29  Dilated  stomach 

30  Dilated  stomach 

31  Normal  stomach 

32  Same  case  as  Fig.  31 

33  Dilatation  and  ptosis  of  the  stomach 

34  Hypernephi'oma    causing    pressure    on    a    normal 

stomach 

3^  Hypernephroma 


Hour-glass  constriction 

Lateral  view 

Hour-glass  constriction 

Perforating  duo- 


13 
15 
15 
15 
15 
17 
17 
17 
19 
19 
21 
21 
23 
23 
25 
25 
25 
27 
27 
29 
29 
29 
31 

31 
31 


GASTRIC  ULCER 

36  Obstruction  of  cesojjhagus 

37  Gastric  ulcer  near  cardia 

38  Same  case  as  Fig.  37 

39  Gastric  ulcer  with  hour-glass  constriction 

40  Cbroiiir  nMsl  lie  ulcer 

41  Chrome  penetrating  gastric  ulcer.     Hom--glass  con- 

striction  

42  Chronic  gastric  ulcer.     Hom--glass  formation 

43  Chronic  gastric  ulcer.     Small  perforating  ulcer 

44  Chronic  gastric  ulcer,  hour-glass  formation.     Perfor- 

ating ulcer 

45  Hour-glass  constriction  of  the  stomach 

46  Chronic  gastric  ulcer 

47  Artist's  drawing  of  same  case  as  Fig.  46 

48  Chronic  gastric  ulcer 

49  Chronic  perforating  gastric  ulcer 

50  Chronic  perforating  gastric  ulcer 

51  Chronic  gastric  ulcer 

52  Chronic  gastric  ulcer  . 

53  Chronic  gastric  ulcer. 

54  Same  case  as  Fig.  53. 

55  Chronic  gastric  ulcer. 

56  Chronic  gastric  ulcer,  adhesions. 

denal  ulcer 

56A     Artist's  drawing  of  same  case  as  Fig.  56.     Plate  I. 

Colored Following 

57  Chronic  gastric  ulcer.     Adhesions 

58  Chi'onic  gastric  ulcer.     Hour-glass  constriction 

69     Artist's  drawing  of  same  case  as  Fig. -58 


Fig.  No.                                                                                   Page  No. 

60  Chi'onic  gastric  ulcer.     Pathological  gall-bladder. ...  51 

61  Same  case  as  Fig.  60.     Six  hours  after  the  bismuth 

meal 51 

62  Chronic  ulcer  of  the  stomach 51 

63  Traumatic  hour-glass  constriction  of  the  stomach  ...  53 

64  Chi'onic  gastric  ulcer 53 

65  Chronic  gastric  ulcer 53 

66  Chi'onic  gastric  ulcer 55 

67  Chronic  gastric  ulcer  with  tumor  mass 55 

68  Ulcer  near  pylorus 55 

69  Chi'onic  ulcer  at  pylorus 57 

70  Small  gastric  ulcer 57 

71  Several  gastric  ulcers.     Duodenal  ulcer 59 

72  Ai'tist's  drawing  of  same  case  as  Fig.  71 59 

73  Chronic  gastric  ulcer  near  the  pylorus 61 

74  Same  case  as  Fig.  73.     Prone  position 61 

75  Same  case  as  Fig.  73  after  resection  of  the  stomach  .  .  61 

76  Pyloric  obstruction.     Ulcer  of  the  pylorus 63 

77  Ulcer  near  pylorus 63 

78  Same  case  as  Fig.  77.     Upright  position 63 

79,  80,  81,  82     Series  of  plates  of  a  small  gastric  ulcer. .  65 

83     Gastric  ulcer  of  stomach.     Hour-glass  constriction .  .  67 

83A     Gastric  ulcer  near  pylorus 67 


GASTRIC  NEW  GROWTH 

84  Key  plate.     Normal  stomach 

85  Ai-tist's  drawing  of  same  case  as  Fig.  86.     Plate  IL 

Colored Following 

86  Inoperable  carcinoma  of  the  stomach 

87  Adenocarcinoma  on  base  of  old  ulcer 

88  Same  case  as  Fig.  87 

89  Same  case  as  Fig.  87 

90  Ai'tist's  ch-awing  of  resected  portion  of  stomach  and 

duodenum 

91  Adenocarcinoma.     Chronic  ulcer 

92  Early  carcinoma  at  pylorus 

93  Early  carcinoma  at  pylorus 

94  Carcinoma  of  pylorus  and  antrum  of  the  stomach. .  . 

95  Early  carcinoma  of  pylorus 

96  Carcinoma  of  pylorus  and  antrum  of  the  stomach. .  . 

97  Ai'tist's  di'awing  of  same  case  as  Fig.  96 

98  Earlv  rarcinonia  nf  antrum  of  the  stomach 


100 

101 

102 

103 

104 

105 

106 

107 

107A 

108 

109 

110 

111 

112 
113 

114 
115 
116 

117 
118 
119 
120 
121 


Inoper: 
Inoper; 
Inojiei,- 
Inoili'l': 
Ino])er; 
Inoper; 


IIk 


stomach. 
st  <  )mach . 
slomach. 
-lomach. 
slomach. 
stcjmach . 


areuioiiia  of  (ii(.' 

Inoperable  carcinoma  of  the  stomach 

Ai'tist's  di'awing  of  same  case  as  Fig.  105 

Intragastric  tumors 

Inoperable  carcinoma  of  the  stomach 

Intragastric  tumors 

Inoperable  carcinoma  of  the  stomach 

Adenocarcinoma  of  the  stomach 

Same  case  as  Fig.  110.  Upright  position  showing 
intragastric  tumor 

Inoperable  carcinoma  at  cardia 

Post-operative  new  growth  involving  antrum  of  the 
stomach 

Inoperable  carcinoma  of  pars  media  and  cardia 

Inoperable  carcinoma  of  stomach  on  base  of  old  ulcer 

Intragastric  tumor  of  the  greater  curvature.  Adeno- 
carcinoma  

Inoperable  adenocarcinoma  at  cardia 

Small  intragastric  tumor  at  cardia 

Extensive  new  growt.h  at  cardia 

Iiioperable  adenocarcinoma  of  the  stomach 

Inoperable  adenocarcinoma  of  pars  media  of  the 
stomach 


LIST   OF   ILLUSTRATIONS 


DUODENUM 

Fig.  No.                                                                              Page  No. 

122  Key  plate.     Normal  stomach 99 

123  Artist's  di'awing  showing  ulcer  on  anterior  wall  of 

the  duodenum 99 

124  Artist's  di'awing  showing  mucosal  sm-face  of  ulcer. .  .  99 

125  Chronic  ulcer  of  duodenum 101 

126  Chronic  ulcer  of  duodenum 101 

127  Chi'onic  ulcer  of  duodenum 101 

128  Chronic  ulcer  of  duodenum 101 

129  Chi'onic  ulcer  of  duodenum 103 

130,  130A     Lateral  view  of  stomach  showing  small  chronic 

ulcer  of  the  superior  surface  of  the  duodenum  ....  103 

131,  131A     Lateral  view  of  stomach  showing  ulcer  on  the 

superior  and  inferior  borders  of  the  duodemmi ....  105 

132  Small  chi-onic  ulcer  of  the  duodenum 105 

133  Same  case  as  Fig.  132.   Fifteen  minutes  after  bismuth 

meal 105 

134  Duodenal    ulcer.     Beginning    new    gi-owth    in    the 

stomach 107 

135  L'lcer  of  the  duodenum.     LHcer  on  lesser  curvatm-e 

of  the  stomach,  posterior  wall 107 

136  Chronic  ulcer  of  the  duodenum 107 

137  Lateral  view  of  same  case  as  Fig.  136 107 

138  Chi-onic  ulcer  of  the  duodemun 109 

139  Clu'onie  ulcer  of  the  duodenum.     Adhesions 109 

140  Chrome  ulcer  of  the  duodenum.     Adhesions 109 

141  Clu'onic  ulcer  of  the  duodeniim.     Gall-stones.     Ad- 

hesions    Ill 

142  Lateral  view  of  same  case  as  Fig.  141 Ill 

143  Chi-onic    ulcer    of    the    duodenum   with    beginning 

perforation Ill 

144  Small  chronic  ulcer  on  superior  border  of  duodemmi.  Ill 

145  Chronic  ulcer  of  duodenum.     Obstructive  type 113 

146  Chronic  ulcer  of  duodenum.     Obstructive  type 113 

147  Small  ulcer  on  superior  border  of  duodenum 113 

148  Chronic   ulcer   of  the   duodenum.     Obhteration   of 

duodenum 115 

149  .^I'tist's  drawing  of  same  case  as  Fig.  148 115 

150  Chronic  ulcer  of  the  duodenum 117 

151  Same  ease  as  Fig.  150.     Plate  III FoDowing  116 

152,  152A    Same  case  as  Fig.  150.     Lateral  view 117 

153  Chronic  ulcer  of  the  duodenum 119 

154  Same  case  as  Fig.  153.     Lateral  view 119 

155  Ulcer  of  the  duodenum 119 

156,  156A     Chi'onic  ulcer  of  the  duodenum 121 

157  Chronic  ulcer  of  the  duodenum,  obstructive  type .  .  .  121 

158  Chronic  ulcer  of  the  duodenum 123 

159  Chronic  ulcer  of  the  duodenum 123 

160  Small  ulcer  of  the  duodemmi 125 

161  Artist's  di'awing  of  same  case  as  Fig.  160 125 

162  Penetrating  idcer  of  the  superior  border  of  the  duo- 

denum    127 

163  Adhesions  about  the  duodenum,  stomach  and  large 

bowel 127 

164  Artist's  drawing  of  same  case  as  Fig.  163 127 

165  Hour-glass  constriction.     Gastric  ulcer  at  the  carcha  129 

166  Same  case  as  Fig.   165,  six  months  later.     Double 

hour-glass  constriction 129 

167  Obstruction  of  transverse  portion  of  the  duodenum. 

Adhesions 129 

168  Fixation  of  duodenum  to  subhepatic  region 131 

169  Adhesions  about  the  descending  duodenum 131 

170  Adhesions  about  the  descending  duodenum 131 

171  Adhesions  about  the  descending  duodenum 131 

172  Extensive  adhesions  about  the  first  portion  of  the 

duodenum 133 

173  Small  ulcer  of  the  duodenum 133 

174  Post-operative  adhesions  from  the  gall-bladder 135 

175  Same  case  as  Fig.  174 135 

176  Same  case  as  Fig.  174 135 

177  Obstruction  of  the  transverse  portion  of  the  duo- 

denum.    Congenital 137 

178  Same  case  as  Fig.  177.     Twenty-four  hours  after  the 

bismuth  meal 137 

179  Lateral  view  of  the  same  case  as  Fig.  178 137 

180  Same  case  as  Fig.  179 137 

181  Primary  carcinoma  of  the  duodenum 139 

GALL-BLADDER 

182  GaU-stones.     Gastric  ulcer.     Adhesions 147 

183  Ai'tist's  drawing  made  at  time  of  operation.     Same 

case  as  Fig.  182 147 

184  Gall-stones 147 


Fig.  No.                                                                                  Page  No. 

185  Same  case  as  Fig.  184 147 

186  GaU-stones 149 

187  One  large  gall-stone 149 

188  GaU-stones 149 

189  Gall-stone 151 

189A    Same  case  as  Fig.  189 151 

190  Two  large  gaU-stones 151 

191  Two  large  gaU-stones 151 

192  Gall-stones 153 

193  GaU-stones 153 

194  GaU-stones 153 

195  GaU-stones 153 

196  Two  small  gall-stones 155 

197  One  large  gall-stone 155 

198  Gall-stones 155 

199  Cholecvstitis.     GaU-stones 155 

200  Pathological  gall-bladder.     GaU-stones 157 

201  Group  of  smaU  gaU-stones 157 

202  Two  small  gall-stones 157 

203  One  gall-stone 157 

204  Two  small  gaU-stones 159 

205  Pathological  gaU-bladder.     Adhesions 159 

206  One  large  gaU-stone 159 

207  One  gall-stone , 159 

208  GaU-stones 161 

209  Large  number  of  small  gaU-stones 161 

210  Large  number  of  gall-stones 161 

211  Several  gaU-stones 161 

212  Gall-stones 163 

213  Pathological  gall-bladder 163 

214  Gall-stones 163 

215  Galkstones 163 

216  Pathological  gall-bladder.     Extensive   adhesions .  .  .  165 

217  Same  case  as  Fig.  216.     Patient  in  upright  position  165 

218  Two  large  gaU-stones 165 

219  Three  gaU-stones 165 


220 

220A 

221 

222 

223 

224 

225 

226 
227 
•228 
229 
230 
231 
232 

233 
234 
235 
236 

237 
238 
239 

240 
241 
242 

243 

244 
245 
246 
247 


248 
249 
250 
251 
252 
253 
254 


SMALL  INTESTINE 

Key  plate.     Anatomical  variation  of  the  stomach 

and  duodenmri 169 

Key  plate  showing  character  of  the  jejunum 169 

Obstruction  of  jejunum  by  adhesion 171 

Adhesions.     Ileal  stasis 171 

Adhesions.     Lane's  kink 173 

Obstruction  of  jejunum  by  annular  carcinoma 173 

Chronic  appendix  and  adhesions,  with  fixation  of 

terminal  ileum 173 

Lane's  kink.     Chronic  appendix 173 

Lane's  kink 175 

Marked  obstruction  of  ileum  due  to  pelvic  bands .  .  .  175 

Extensive  adhesions  about  the  CEecum  and  ileum ....  175 

Marked  rUlatation  of  the  terminal  ileum 177 

Adhesions  foUowing  perforating  appendix 177 

Same  case  as  Fig.  231.    Twenty-four  hours  after  the 

bismuth  meal 177 

Lane's  kink 179 

SmaU  annular  growth  of  ileum 179 

Diverticulum  of  jejunum 181 

Same  case  as  Fig.  235.     Twenty-four  hours  after  the 

bismuth  meal 181 

Same  case  as  Fig.  235.     Enema  method 181 

Diverticulum  of  jejunum 183 

Extensive  adhesions  about  the  appendix  involving 

the  transverse  colon 183 

Fixation  of  terminal  ileum 183 

Adhesions  about  the  ileum 183 

Extensive  membrane  formation  and  chronic  appen- 

cUx -...-.....  185 

Tubercular  caecum 1S5 

Lane's  kink.     Adhesions 185 

Adhesions 187 

Displacement  of  ileum  by  dilated  urinary  bladder. .  .  187 

Displacement  of  ileum  by  gravid  uterus 187 

APPENDIX 

Key  plate.     Normal  large  bowel 193 

Chi'onic  appendix 193 

Clironic  appendix 195 

Chronic  appendix  with  various  concretions 195 

Chi'onic  appendix 197 

Chronic  appendix.     PericoHc  membrane 197 

Chronic  appendix 197 


LIST   OF   ILLUSTRATIONS 


XI 


Fig.  No.  Page  No. 

255  Chi-onic  appendix 199 

256  Same  case  as  Fig.  255.    Twenty-foui'  hoiu's  after  the 

bismuth  meal 199 

257  Chi-onio  appendix 199 

258  Chronic  appendix 201 

259  Chronic  appendix 201 

260  Chronic  appendix.     Adhesions  about  the  ascending 

colon 201 

261  Adherent  and  retrocsecal  appendix 203 

262  Appendix  fixed  and  kinked  in  mid  portion 203 

263  Chronic  appendix 203 

264  Chronic  appendix 205 

265  Chronic  appendix 205 

266  Chronic  appendix 205 

267  Chronic  appendix 207 

268  Ai'tist's  drawing  of  same  case  as  Fig.  267 207 

26^  Chi-onic  appendix.     Adhesions  about  the  ascending 

colon 207 

270  Chronic  appendix 207 

271  Chronic  appendix 209 

272  Cliiniii,-  ;ip|,ciuiix 209 

273  Cluoni.'  .ippendix 209 

274  Clirouic  a|)pendix,  adherent  to  the  caecum 209 

275  Chronic  appendix 211 

276  Lane's  kink.     Adherent  and  kinked  appendix 211 

277  Chi'onic  appendix 211 

278  Dilated  lumen  of  the  appendix 211 

280  Chi-onic  appendix 213 

281  Chronic  appendix.     GaU-stones 213 

282  Chronic  appendix 213 

283  Chronic  appendix 215 

284  Artist's  di'awing  of  same  case  as  Fig.  283 215 

285  Appendix  retrocEecal  and  fixed  in  subhepatic  region  215 

286  Chronic  appendix.     Adhesions 215 

287  Chi'onic  appendix,  retrocsecal  and  adherent 217 

288  Chronic  appendix  with  concretions 217 

289  Same  case  as  Fig.  288.    Forty-eight  hovas  after  the 

bismuth  meal 217 

290  Chi-onic  appendix 217 

291  Chronic  appendix 219 

292  Chi-onic  appendix  with  adhesions 219 

293  Same  case  as  Fig.  292.    Twenty-four  hours  after  the 

bismuth  meal 219 

294  Chronic  appendix.     Extensive  adhesions 221 

295  Chronic  appendix.     Boy  nine  years  of  age 221 


LARGE  INTESTINE  —  ADHESIONS 

296  Key  plate.     Normal  bowel.     Plate  made  twenty-fom- 

hom-s  after  the  bismuth  meal 227 

297  Extensive  adhesion  formation  about  the  appendix, 

stomach  and  large  bowel 227 

298  Tuberculosis  of  the  csecum  and  most  of  the  large 

bowel 229 

299  Extensive  adhesions  about  the  hepatic  flexm-e 229 

300  Pericolic   membrane.     Dilated   caecum   due  to   ad- 

hesions    231 

301  Pericolic  membrane  and  adhesions 231 

302  Artist's  drawing  of  same  case  as  Fig.  301 231 

303  Pericolic  membrane  and  retrocaecal  appendix 233 

304  Adhesions  about  caecum  and  proximal  portion  of  the 

transverse  colon 233 

305  Adhesions  about  the  CEecum  and  transverse  colon .  .  .       233 

306  Adhesions.     Partial    obstruction    of   the    ascending 

colon  due  to  gall-bladder  adhesions 235 

307  Adhesions  from  gall-bladder  causing  obstruction  of 

the  ascending  colon 235 


Fig.  No.                                                                                   Page  No. 

308  Adhesions  about  the  ascending  colon 235 

309  Obstruction  of  ascending  colon  due  to  adhesions  ....  237 
309A     Adhesions  about  ascending  colon  due  to  membrane  237 

310  Adhesions  about  ascending  colon.     Chronic  appendix  237 
311,  311A     Incompetency  of  the  ileocaecal  valve 239 

312  Obstruction  of  transverse  colon  due  to  abscess  of  liver  239 

313  Hirschbrung's  disease.     Congenital  dilatation  of  the 

large  intestine.     Child  six  weeks  old 241 

314  Adhesions  about  the  ascending  colon  and  caecum. .  .  .  241 

315  Artist's  di-awing  of  same  case  as  Fig.  314 241 

316  Obstruction  of  ascending  colon  due  to  tubercular 

peritonitis 243 

317  Pericolic  membrane.     Clironic  appendix 243 

318  Fixation  of  transverse  colon 245 

319  Extensive  adhesions  in  upper  right  quadrant 245 

320  Pericolic  membrane  of  the  ascending  colon 247 

321  Adhesions  about  the  proximal  portion  of  the  trans- 

verse colon 247 

322  Adhesions  about  the  ascending  and  proximal  portion 

of  the  transverse  colon 247 

323  Extensive  adhesions  about  the  ascending  colon  caus- 

•  ing  incompetency  of  the  ileocaecal  valve 249 

324  Same  case  as  Fig.  314 249 


INTESTINAL    NEW   GROWTH 

325  Ai-tist's  drawing.     Plale  IV.     Colored Following  250 

326  Small  intra-iiilcsliiial  new  growth  of  CEecum 251 

327  Extensive  new  ninulli  of  caicum 251 

328  New  growth  at  hcralic  flexui-e 253 

329  Small  annular  new  growth  at  hepatic  flexiu-e 253 

330  Ai'tist's  drawing  of  same  case  as  Fig.  329 253 

331  New  growth  of  proximal  portion  of  transverse  colon.  255 

332  Large  inoperable  new  growth  of  transverse  colon. .  .  .  255 

333  Inoperable   intra-intestinal   new  growth   of   splenic 

flexure 257 

334  Same  case  as  Fig.  333 257 

335  Intra-intestinal  tumor  at  splenic  flexm-e 259 

336  Inoperable   carcinoma   involving   descending   colon 

and  sigmoid 259 

337  Small  annular  carcinoma  of  descending  colon. .  .....  261 

338  Extensive  involvement  of  the  descending  colon  due 

to  new  growth 261 

339  Ai'tist's   di-awing   of  same  case  as  Fig.  338.     Plate 

V.     Colored Following  260 

341  Small  annular  new  growth  of  sigmoid 263 

342  Ai'tist's  drawing 263 

343  New  growth  of  the  sigmoid 265 

344  Extensive  new  growth  of  the  entire  sigmoid 265 

345  Complete  involvement  of  the  whole  pelvic  colon  due 

to  new  growth 267 

346  Small  annular  carcinoma  of  descending  colon 267 

347  Small  annular  carcinoma.     Diverticulitis 269 


DIVERTICULITIS 

348  Diverticulitis  of  the  large  intestine 273 

349  Diverticulitis 273 

350  Multiple   diverticula 273 

351  Multiple  diverticula 273 

352  Diverticula  of  the  pelvic  colon 275 

353  Artist's  chawing.     Plate  VI.      Colored .....  Following  274 

354  Several  large  diverticula  of  the  descending  colon ....  275 

355  Diverticulitis  of  the  entire  colon 275 

356  Multiple  diverticulitis 277 

357  Multiple  diverticuhtis 277 


THE  ROENTGEN  DIAGNOSIS 

OF   SURGICAL   LESIONS   OF   THE 

GASTRO-INTESTINAL  TRACT 


SECT  I  OX   I 


NORMAL   STOMACH 

Indirect  IMethod  —  Direct  AIethod  —  ]^Ieals  —  General  EorTixE 
AND  Technique  —  Apparatus  —  Normal  Stomach 

In  the  Roentgen  investigation  of  the  gastro-intestinal  tract,  it  is  evident  that  two 
schools  have  developed.  One,  the  Continental  school  from  which  the  pioneer  work  came; 
the  other,  the  American  school  Great  credit  must  be  given  to  the  early  investigators  for 
their  very  thorough  and  exact  work.  Unfortunately  they  built  up  their  technique  on  ques- 
tionable ground  and  soon  arrived  at  a  point  where  no  further  advance  could  be  made. 
To  better  explain  the  method  carried  out  in  this  volume,  particularly  in  the  study  of  gastric 
and  duodenal  lesions,   let   us  outline  brieflv  the  two  schools. 


INDIRECT   :\IETHOD 

The  Continental  investigators,  Reider,  Rosenthal,  Holznecht.  Hsenisch  and  others, 
were  forced  by  the  necessity  of  their  clinics  to  depend  upon  the  Roentgenoscope  almost 
entirely.  Their  clinics  were  large,  lacked  efficient  apparatus,  and  expense  was  a  considera- 
tion; so  that  altogether  Roentgenoscopy  seemed  the  simplest  and  best  method  to  use.  Con- 
sequently their  work  has  been  based  upon  the  signs  and  findings  which  could  be  brought 
out  by  Roentgenoscopy.  From  this  basis  of  diagnosis,  they  evolved  what  has  been  caUed  the 
"symptom-complex."  That  is,  a  number  of  Roentgenoscopic  and  clinical  signs,  largely 
of  a  functional  nature,  were  grouped  together,  and  on  these  their  diagnoses  were  founded. 
Among  the  signs  upon  which  a  great  deal  of  stress  was  laid,  for  example,  in  the  study  of 
gastric  ulcer  were  peristalsis,  antiperistalsis,  hj'perperistalsis,  increased  and  cUminished 
emptying  time  of  the  stomach,  various  spasms,  six-hour  gastric  residue,  pressure  tender- 
points,  and  the  clinical  history  including  the  laboratory  findings.  Without  doubt,  much 
valuable  data  was  obtained  from  this  study  and  up  to  a  certain  point  progress  made  in 
the   diagnosis   of  diseases   of  the   gastro-intestinal  tract. 

It  has  been  found,  however,  that  this  method  of  stud}',  especially  when  applied  to  the 
duodenal  region,  has  frequently  proved  inadequate,  not  altogether  in  indi\ddual  cases, 
but  in  studying  collectively  a  series.    Many  cases  were  classed  as  negative  which,  in  the 

1 


2  THE  EOENTGEN  DIAGNOSIS   OF   SURGICAL  LESIONS 

light  of  our  knowledge,  must  ha^^e  jdelded  positive  pathological  data  if  a  more  careful 
study  had  been  made.  It  is  fair  to  say  that  the  errors  of  diagnosis  were  not  so  much  errors 
of  commission  as  of  omission.  Alany  investigators,  especially  Americans,  felt  the  neces- 
sity^ for  more  accurate  diagnosis  than  was  possible  with  this  method. 


DIRECT   METHOD 

To  Le'nds  Gregory  Cole  of  New  York  must  be  given  a  great  deal  of  credit,  who  as 
pioneer  broke  away  from  the  early  teachings  of  the  Continental  school.  He  was  the  first 
to  demonstrate,  by  means  of  serial  plates,  the  actual  anatomical  variation  produced  by 
the  lesion.  It  was  on  this  direct  Roentgen  evidence,  viz.,  the  exhibition  of  the  very  lesion 
itself,  that  Cole  based  his  diagnosis.  This  method  is  called  the  direct  or  American  school. 
It  is  in  contrast  to  the  indirect  method,  or  Continental  school,  in  which  the  diagnosis 
is  based  on  a  somewhat  uncertain  combination  of  clinical  symptoms  and  varied  Roent- 
genoscopic  manifestations  of  motility. 

In  our  practice  and  in  the  study  of  this  collection  of  cases,  we  have  endeavored  as 
far  as  possible  to  applj'  the  principles  of  the  direct  school.  In  each  case  we  have  tried 
to  show  on  the  plate  the  actual  lesion. 


MEALS 

The  meal  most  favored  by  the  Continental  workers,  and  still  used  today  by  the  ma- 
jority, is  the  standard  Reider  meal.  This  originally  consisted  of  forty  grammes  of  bismuth 
subcarbonate  and  three  hundred  cubic  centimeters  of  cooked  cereal.  Later,  an  equivalent 
amount  of  barium  sulphate  was  substituted  for  the  bismuth.  Thousands  of  cases  have 
been  studied  with  this  meal  and  much  valuable  data  has  been  accimiulated.  However, 
American  investigators  found  the  Reider  meal  too  coarse.  It  failed  to  fiU  out  the  duodenum 
completely  enough  for  an  accurate  observation  and  made  the  visualization  of  the  appendix 
quite  improbable  and  a  rarity.  Roentgenologists  then  began  to  use  other  media,  as  arti- 
ficially prepared  milk,  buttermilk,  etc.  With  such  a  medium  it  was  possible  to  demon- 
strate lesions  from  the  start.  It  easily  filled  out  crevices  and  folds.  It  is  quickly  prepared, 
easily  obtainable  and  quite  palatable.  IncidentaU}'  it  was  found  that  the  bismuth  was  kept 
in  suspension  a  longer  time  throughout  the  gastro-intestinal  tract  than  with  aU  other  meals. 
As  a  consequence,  the  constant  demonstration  of  the  appendix  among  other  conditions 
in  the  right  lower  quadrant  is  a  fact.  It  is  necessary  with  the  buttermilk  meal  to  use 
two  to  three  times  the  amount  of  bismuth  contained  in  the  Reider  meal.  The  writers, 
for  instance,  are  using  ninety  grammes  of  bismuth  subcarbonate  (slightly  increasing  this 
when  using  barium  sulphate)  with  five  hundred  cubic  centimeters  of  buttermilk  and 
water. 

As  a  result  of  the  marked  variation  between  the  two  meals,  it  is  incorrect  to  use  the 
same  functional  data  for  diagnosis  in  comparing  the  buttermilk  meal  with  the  Reider  or 
cereal  meal.  Conclusions  drawn  as  to  the  emptying  time  of  the  stomach,  six-hour  gastric 
stasis,  position  of  the  head  of  the  bismuth  column  in  six  hours,  etc.,  using  the  buttermilk 
bismuth  meal,  cannot  be  compared  with  the  same  cases  if  the  Reider  meal  is  used. 

This  is  a  point  which  has  not  been  appreciated  entirely  by  our  own  Roentgenologists. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS  '  3 

Either  through  lack  of  care  or  interest,  they  have  used  all  kinds  of  media,  buttermilk, 
plain  milk,  water,  potato  pap,  malted  milk,  soup,  cereals,  etc.,  and  have  varied  not  only 
the  amount  of  bismuth  or  barium,  but  have  given  double  meals,  half  of  a  meal,  and  divided 
meals  in  various  ways  so  that  the  results  obtained  in  their  studies  cannot  be  standardized. 
Yet,  in  spite  of  this,  these  investigators  have  continued  to  publish  their  observations  based 
on  the  deductions  of  the  Reider  technique,  which  they  did  not  employ.  Obviously  they 
cannot   be   correct. 

The  only  course  left  for  those  who  wish  to  use  this  functional  data  is  to  adhere  strictly 
to  the  technique  of  Reider,  Rosenthal  and  others,  and  accumulate  a  large  number  of  cases. 
If  one  attempts  to  vary  the  mixture  in  any  way,  one  must  check  up  one's  work  by  the 
operative  results.  This  has  been  done  in  part  bj'  one  of  our  American  clinics  having  tre- 
mendous material.  They  now  are  undoubtedly  in  a  position  to  draw  correct  conclusions 
as  to  the  motility  of  the  stomach  with  their  particular  technique. 

Finally,  let  us  emphasize  the  importance  of  a  standard  meal.  Only  with  a  uniform 
meal  and  technique  can  the  results  of  different  investigators  be  correlated.  We  have  found 
the  simple  buttermilk  meal  satisfactory,  principally  because  it  fills  out  the  duodenal  cap 
and  the  appendix  to  better  advantage. 


GENERAL   ROUTINE  AND   TECHNIQUE 

Our  general  routine  is  as  follows  (special  points  in  the  technique  will  be  brought 
up  in  the  various  sections).  The  patient  presents  himself  for  examination  in  the  morning 
without  breakfast.  We  have  found  that  a  cup  of  coffee  and  toast  at  least  two  hours  before 
the  examination  in  no  way  interferes.  Several  plates  are  first  made  of  the  gall-bladder 
region.  Frequently  the  entire  abdomen  is  examined  to  rule  out  kidney  stone  and  also  to 
obtain  some  idea  as  to  the  distribution  of  gas,  the  general  size  and  position  of  the  liver, 
spleen,  and  kidneys.  Such  a  plate  is  frequently  valuable  as  a  record  for  comparison  with 
the  plates  made  after  the  bismuth  has  been  given. 

The  meal  is  given  to  the  patient  in  two  large  glasses.  As  the  first  glass  is  taken  the 
patient  is  studied  with  the  Roentgenoscope,  attention  being  paid  to  the  oesophagus  and 
the  manner  in  which  the  stomach  fills.  The  second  glass  is  taken  at  once  and  the  first 
plate  then  exposed. 


APPARATUS 

As  to  apparatus,  we  have  found  that  any  transformer  producing  energy  enough  to 
make  an  exposure  within  a  second  and  a  half  is  satisfactory.  In  passing,  we  have  not 
found  any  portable  apparatus  of  sufficient  power  for  gastro-intestinal  work. 

The  standard  tubes  are  all  satisfactory.  Some  of  the  more  recently  marketed  tubes 
have  made  the  "lateral"  view  possible  with  greater  precision. 

It  has  been  our  custom  to  use  intensifying  screens  in  all  our  gastro-intestinal  work. 
The  screen  allows  us  to  use  a  softer  tube  and  a  shorter  exposure.  This  is  of  benefit  both 
to  the  patient  and  to  the  owner  of  the  tube. 

Plates  are  made  routinely  after  the  meal,  again  at  six  hours,  and  again  at  twentj'- 
four  hours.  A  light  lunch  is  allowed  between  the  first  and  six-hour  plate.  The  other  cus- 
tomary meals  are  not  interfered  with. 


4  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 

Plates  are  taken  in  various   positions.    The   bulk  of   the   work  is  done   routinelj^   with 
the  patient  in  the  prone  position. 


NORMAL  STOMACH 

The  normal  stomach  is  a  collapsible  bag,  hanging  free  in  the  abdominal  cavity.  It 
is  fixed  at  the  cardiac  orifice  and  somewhat  loosely  held  along  the  lesser  curvature  by 
the  gastro-hepatic  ligament.  It  must  be  borne  in  mind  that  the  size  of  the  normal  stomach 
depends  absolutely  on  its  contents  and  that  its  shape  depends,  in  a  great  measure,  on 
the  surrounding  organs.  A  thorough  acquaintance  with  the  normal  stomach  and  its  normal 
variations  is  fundamental  for  a  recognition  of  any  pathological  condition.  Our  concep- 
tion of  the  normal  stomach  is  based  on  the  Roentgen  picture  made  within  five  minutes 
following  the  regular  meal.  The  exposures  are  made  both  with  the  patient  upright  and 
prone,  the  plates  always  against  the  abdomen. 

The  stomach  can  be  divided  into  a  larger  cardiac  part  and  a  smaller  pyloric  part. 
The  cardiac  portion  consists  of  the  fundus  and  body,  sometimes  called  the  pars  media,  the 
fundus,  according  to  Hertz,  being  the  segment  of  the  stomach  which  lies  above  a  hori- 
zontal plane  passing  through  the  cardiac  orifice.  In  the  erect  position  the  body  of  the 
stomach  is  situated  entirely  to  the  left  of  the  middle  line  and  is  either  vertical  or  inclined 
slightly  towards  the  right. 

The  pyloric  portion  consists  of  the  antrum,  or  pars  pylorica,  and  the  pylorus.  The 
"incisura  angularis"  has  sometimes  been  described  as  separating  the  pars  media  from 
the  pars  pylorica.  This  is  a  sharp  indentation  on  the  lesser  curvature.  We  have  found  this 
incisura  to  be  rather  inconstant,  particularly'  with  the  full  meal.  The  pars  pylorica  or 
antrum  is  directed  upwards  and  somewhat  backwards.  It  narrows  gradually  and  ends 
at  the  pylorus.  The  pylorus  appears  as  an  isthmus  of  bismuth  connecting  the  stomach 
with  the  first  portion  of  the  duodenum.  It  varies  from  a  quarter  of  an  inch  in  diameter 
to  the  size  of  a  thread.    It  is  usually  from  one  quarter  to  a  third  of  an  inch  in  length. 

The  shape  of  the  stomach  depends  to  a  great  measure  on  its  muscular  tone  and  on 
the  surrounding  organs.  The  lesser  curvature  has  a  more  or  less  rigid  attachment  so  that 
changes  in  size  and  shape  take  place  at  the  expense  of  the  greater  curvature.  Various 
kinds  of  normal  stomachs  have  been  described,  such  as  fish-hook,  cow's  horn,  and  text- 
book type.    These  terms  have  no  pathological  significance. 

The  muscular  tone  of  the  gastric  walls  is  one  factor  in  determining  the  shape.  A  hy- 
pertonic stomach  is  likely  to  be  high  up  in  the  abdominal  cavity,  occupying  a  horizontal 
position  with  active  peristalsis.  On  the  other  hand,  an  atonic  stomach  will  be  low,  the 
greater  curvature  may  reach  almost  the  pelvic  brim,  the  general  axis  will  be  vertical  rather 
than  horizontal.  There  will  be  little  evidence  of  peristalsis.  Such  a  stomach  will  be  of 
the  "fish-hook"  variety.  There  are  all  grades  between  these  two  types  and  all  within 
the  normal  limits. 

The  development  of  the  individual  has  a  bearing  on  the  shape  and  position  of  the 
stomach.  For  instance,  a  stout  individual  with  considerable  abdominal  fat  will  show  a 
very  high  stomach.  In  fact,  frequently  the  body  of  the  stomach  will  be  held  so  high  that 
in  the  anteroposterior  view  it  will  actually  overlie  the  pylorus  and  duodenum.  On  the 
other  hand,  in  a  thin,  emaciated  individual  the  stomach,  not  having  any  supporting  ab- 
dominal fat,  will  be  found  resting  down  in  the  true  pelvis.  Each  type  of  stomach  is  normal 
for  that  particular  individual. 


THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS  5 

Extreme  pressure  may  give  a  variation  to  the  outline  of  a  normal  stomach.  Pressure 
from  the  spine  in  a  prone  position  will  oftentimes  give  an  apparent  defect  in  the  antrum 
or  body  of  the  stomach.  Pressure  from  a  distended  colon,  particularly  at  the  splenic  flexure, 
may  give  a  peculiar  irregularity  in  the  greater  curvature.  Enlarged  spleen,  or  kidney! 
cysts  of  the  pancreas,  ascites,,  all  these  may  produce  distortions  of  a  perfectlv  normal 
stomach. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


NORMAL  STOMACH 

Figure  1 

PATIENT  — POSITION:     Woman,  age  25.     Prone. 

ROENTGEN  CONCLUSIONS:     Normal. 

OPERATIVE  FINDINGS:     Exploratory.     Stomach  and  duodenum  found  normal. 

Key  plate. 

1  Region  of  cardia  distended  with  air. 

2  Pars  media. 

3  Pars  pylorica,  or  antrum. 

4  Pylorus  relaxed. 

5  First  portion  of  the  duodenum.  "Bishop's  Cap."  Roentgenographically  the  first  portion  of  the 
duodenum  shows  the  superior  and  inferior  border  ahvaj's  smooth  in  outline.  The  base,  or  pyloric 
region,  is  also  smooth. 

6  Second  portion  of  the  duodenum. 

Note  the  valvulse  coimiventes  which  distinguish  it  from  the  stomach  and  first  portion  of  the  duodenum. 
Histologically  the  stomach  and  first  portion  are  essentially  the  same. 

7  The  third,  or  transverse  portion,  of  the  duodenum.  This  passes  transversely  and  to  the  left  in  front 
of  the  vertebral  column  and  is  partly  obscured  by  the  stomach.  Note  at  the  junction  of  the  second 
and  third  portions  a  narrowing  which  is  physiological.  In  the  prone  position  this  is  partly  due  to 
pressure.     Note  the  tendencj'  of  the  duodenum  to  dilate  before  food  passes  this  point. 


Figure  2 

PATIENT  — POSITION:     Woman,  age  23.     Prone. 

ROENTGEN  CONCLUSIONS:     Anatomical  variation  of  the  stomach  and  duodenum. 

OPERATIVE  FINDINGS:     General  exploratory.     Negative. 

Kej'  plate. 

1  Pyloric  region,  showing  in  the  antrum  the  effect  of  pressure  from  the  spine. 

2  Poorly  filled  first  portion  of  the  duodenum. 

3  Variation  in  the  position  of  the  descending  duodenum. 

4  Tj'pical  plate  showing  character  of  the  jejunum. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


Figure  3 
PATIENT  — POSITION:     Man,  age  40.     Lateral. 
ROENTGEN  CONCLUSIONS:     Normal  stomach,  lateral  view. 
OPERATIVE  FINDINGS:     None. 

Key  plate. 

It  is  to  be  observed  that  in  the  lateral  position  both  the  posterior  and  anterior  walls  of  the  stomach  are 

shown. 

The  first,  descending,  and  transverse  portions  of  the  duodenum  are  relatively  in  the  same  position  in  the 

lateral  view  as  in  the  prone. 

This  is  particularly  true  in  well-nourished  individuals,  of  whom  this  patient  was  one. 

1  Cardia. 

2  Pars  media. 

3  Posterior  wall. 

4  Anterior  wall. 

5  Antrum  of  the  stomach. 

6  Pylorus. 

7  First  portion  of  the  duodenum,  or  bulbus  duodeni,  or  "cap." 

8  Second  portion,  or  descending  duodenum. 

Q     Third  or  transverse  portion  of  the  duodenum. 


Figure  4 
PATIENT  — POSITION:     Woman,  age  34. 

ROENTGEN  CONCLUSIONS:     Normal  stomach,  lateral  view. 
OPERATIVE  FINDINGS:     No  operation. 

Key  plate. 

1  Pylorus. 

2  First  portion  of  the  duodenum. 

3  Descending  portion  of  duodenum  which  is  poorly  filled. 

In  a  poorly  nourished  individual  the  stomach  may  be  obscured  in  part  by  the  vertebrae,  as  also  the  descending 
portion  of  the  duodenum. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL 


LESIONS 


10  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  5 

PATIENT  —  POSITION:     Man,  age  27.     Prone. 
ROENTGEN  CONCLUSIONS:     Normal  stomach. 
OPERATIVE  FINDINGS:     No  operation. 

A     Pylorus. 

B     Poorly  filled  first  portion  of  the  duodenum. 

This  lack  of  filling  of  the  first  portion  of  the  duodenum  may  be  in  part  due  to  spasm  after  the  bismuth  meal. 


Figure  6 

Lateral  view  of  Figure  5. 

1  Antrum. 

2  First  portion  of  the  duodenum. 

3  Beginning  of  descending  portion  of  duodenum. 

This  lateral  view  shows  how  well  the  first  portion  of  the  duodenum  can  be  demonstrated. 


Figure  7 

The  same  case  as  Figure  5. 

A     The  effect  of  pressure  of  the  spine  upon  the  stomach  which  occurred  throughout  the  examination.   This 

can  be  overcome  by  examining  the  case  in  the  upright  position. 
B     Pjdorus. 
C     First  portion  of  the  duodenum. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


11 


12  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  8 

PATIENT  — POSITION:     Woman,  age  27.     Prone. 
ROENTGEN  CONCLUSIONS:     Normal  stomach. 
OPERATIVE  FINDINGS:     No  operation. 

A     Pylorus. 

B     First  portion  of  the  duodenum. 

C     Junction  of  the  descending  and  transverse  portions  of  the  duodenum. 


Figure  9 

The  same  case  as  Figure  8  taken  in  the  upright  position. 

This  plate  shows  the  extreme  dilatation  and  ptosis  of  the  stomach,  also  the  difficulty  of  showing  the  first 

portion  of  the  duodenum  if  one  were  to  e.xamine  with  the  Roentgenoscope. 

A     First  portion  of  duodenum. 


Figure  10 

Same  case  as  Figures  8  and  9  six  hours  later  with  a  small  amount  of  gastric  residue,  most  of  the  bismuth 

being  in  the  ileum  and  large  bowel. 

A    Gastric  residue. 

B     Terminal  ileum. 

C     CEecum. 

D     Transverse  colon. 

Figure  11 

Same  case  showing  marked  ptosis  of  the  transverse  colon,  twenty-four  hours  after  Figure  10. 

A    Csecum. 

B     Transverse  colon. 

C     Rectum. 


THE   ROENTGEN    DIAGNOSIS   OF   SURGICAL   LESIONS 


13 


FIGURE   10 


FIGURE   U 


14  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  12 

PATIENT  — POSITION:     Woman,  age  23.     Prone. 
ROENTGEN  CONCLUSIONS:     Normal  stomach. 
OPERATIVE  FINDINGS:     No  operation. 

It  was  impossible  to  fill  the  first  portion  of  the  duodenum  in  the  prone  position. 

Note  the  well-filled  descending  portion  of  the  duodenum. 

A     Pylorus. 

B     Poorly  filled  first  portion  of  the  duodenum. 

C     Descending  duodenum. 


Figure  13 

The  same  case  in  the  upright  position  demonstrating  the  changed  relations  which  the  stomach,  duodenum, 

and  jejunum  assume  in  this  position. 

A     Rugae  of  the  stomach  coated  with  bismuth. 

B     Pylorus. 

C     First  portion  of  the  duodenum. 

D    Jejunum. 

Figure  14 

PATIENT  — POSITION:     Woman,  age  48.     Prone. 

ROENTGEN  CONCLUSIONS:     Normal  stomach.     Ptosis  and  dilatation. 

OPERATIVE  FINDINGS:     No  operation. 

This  plate  illustrates  the  effect  of  our  usual  bismuth  meal. 

Owing  to  the  dilatation  of  the  stomach  and  a  certain  amount  of  ptosis,  the  bismuth  meal  given  was  not 

enough  to  fill  the  stomach  completely  and  to  relieve  the  pressure  effect  from  spasm. 

A    Cardia. 

B     Antrum. 

C     Pylorus. 

D     First  portion  of  the  duodenum. 

Figure  15 

The  same  case  as  Figure  14  taken  in  the  upright  position. 
There  is  considerable  ptosis  and  dilatation  of  the  stomach. 
A     Antrum. 
B     First  portion  of  the  duodenum. 


THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL  LESIONS 


15 


FIGURE  12 


FIGURE  13 


FIGURE  14 


FIGURE  15 


16  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL  LESIONS 


Figure  16 

PATIENT  — POSITION:     Woman,  age  23.     Prone. 
ROENTGEN  CONCLUSIONS:     Normal  stomach. 
OPERATIVE  FINDINGS:     No  operation. 

This  plate  shows  the  average  tj'pe  of  stomach  in  the  poorly-nourished  individual. 

The  upright  position  shows  considerable  ptosis,  a  general  dilatation  with  some  six-hour  gastric  stasis. 

A    Antrum. 

B     First  portion  of  the  duodenum  with  beginning  of  the  second  and  descending  portions. 

C     Descending  portion. 


Figure  17 

The  same  case  six  months  later. 

This  plate  is  used  to  demonstrate  the  fact  that  the  stomach  Roentgenographically  has  an  individuality  and 

unless  diseased  will  always  appear  the  same  in  successive  examinations  employing  the  same  technique. 

A     Antrum. 

B     Note  how  the  duodenum  at  this  time  is  an  exact  duplicate  of  Plate  16. 


Figure  18 


The  six-hour  plate  of  Figures  16  and  17. 

A     Gastric  residue. 

B     Bismuth  in  the  ileum. 

C     Caecum. 

D     Transverse  process. 


THE   ROENTGEN   DIAGNOSIS   OF  SURGIGAT.   LESIONS 


17 


FIGURE    16 


FIGURE  17 


FIGURE   18 


18  THE  ROENTGEN   DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  19 
PATIENT  — POSITION:     Woman,  age  33.     Prone. 

ROENTGEN  CONCLUSIONS:     Normal  stomach.     Dilatation  and  ptosis. 
OPERATIVE  FINDINGS:     No  operation. 

A  Antrum. 
B  Pylorus. 
C     First  portion  of  duodenum. 


Figure  20 


The  same  case,  upright  position. 
A    Area  of  hypersecretion. 
B     Level  of  bismuth. 


THE   ROEXTGEX   DIAGXOSIS   OF  SURGICAL  LESIONS 


19 


FIGURE    19 


FIGURE  20 


20  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  21 

PATIENT  —  POSITION:     Woman,  age  22.     Prone. 

ROENTGEN  CONCLUSIONS:     Dilated  stomach. 

OPERATIVE  FINDINGS:     Cholecystitis.     No  evidence  of  disease  of  the  stomach  or  duodenum. 

A    Antrum  of  stomach. 

B    First  portion  of  duodenum. 

Figure  22 

The  same  case  standing  which  shows  the  relative  amount  of  ptosis. 
A    Greater  curvature  of  stomach. 


THE   ROEXTCxEX   DIAGNOSIS   OF   SURGTCAL   LESIONS 


21 


FIGURE    21 


FIGURE    22 


22  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  23 

PATIENT  — POSITION:     Woman,  age  30.     Prone. 

ROENTGEN  CONCLUSIONS:     Normal  stomach. 

OPERATIVE  FINDINGS:     Chronic  appendix.     No  evidence  of  disease  of  the  stomach  or  duodenum. 

A     Poorly  filled  duodenum,  partly  due  to  pressure  of  the  duodenum. 


Figure  24 

The  same  case  standing  shows  a  well  defined  antrum,  pylorus,  and  first  portion  of  the  duodenum. 
A     Note  the  fluid  level. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


23 


FIGURE   23 


FIGURE  24 


24  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  25 

PATIENT  —  POSITION:     Woman,  age  33.     Prone. 

ROENTGEN  CONCLUSIONS:     Normal  stomach. 

OPERATIVE  FINDINGS:     Cholecystitis.     No  evidence  of  disease  of  the  stomach  or  duodenum. 

A     Poorly  filled  antrum. 

B     First  portion  of  the  duodenum. 


Figure  26 

By  waiting  a  short  time  after  the  bismuth  meal  a  compl(>te  filling  of  the  antrum  and  duodenum  can   l)e 

shown. 

A  and  B  show  a  complete  filling  of  the  antrum  and  duodenum. 


Figure  2  7 

PATIENT  —  POSITION:     Woman,  age  28.     Prone. 

ROENTGEN  CONCLUSIONS:     Normal  stomach. 

OPERATIVE  FINDINGS:     Cholecystitis.     No  evidence  of  disease  of  the  stomach  or  duodenum. 

This  plate  serves  to  illustrate  the  normal  contraction  of  the  pyloric  sphincter.     It  is  not  pathological,  Init 

merely  a  large  sphincter. 

A    Antrum. 

B     Pyloric  sphincter. 

C     First  portion  of  the  duodenum. 

D     Second  portion  of  the  duodenmii. 

E     Pressure  of  the  gall-bladder. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


25 


FIGURE   25 


FIGURE   26 


26  THE  ROENTGEN   DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  28 

PATIENT  — POSITION:     Woman,   age  23.     Prone. 
ROENTGEN  CONCLUSIONS:     Normal  stomach. 
OPERATIVE  FINDINGS:     Chronic  appendix.     Lane's  kink. 

This  plate  should  be  contrasted  \vith  Figure  27. 

Here  a  larger  amount  of  bismuth  is  seen  passing  a  small  sphincter. 

A     Effect  of  pj'loric  sphincter  on  bismuth  mass. 

B     First  portion  of  the  duodenum. 

C     Character  of  jejunum  as  demonstrated  on  the  Roentgen  plate  by  the  passage  of  bismuth. 

D     Character  of  the  ileum  as  compared  with  the  jejunum. 


Figure  29 

PATIENT  — POSITION:     Woman,  age  33.     Prone. 
ROENTGEN  CONCLUSIONS:     Large  dilated  stomach. 
OPERATIVE  FINDINGS:     No  operation. 

A  Antrum. 
B  Pylorus. 
C     First  portion  of  the  duodenum. 


THE   ROEXTGEX  DIAGNOSIS   OF   SURCtICAL   LESIOXS 


27 


FIGURE  28 


FIGURE   29 


28  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  30 

PATIENT  — POSITION:     Woman,  age  27.     Prone. 
ROENTGEN  CONCLUSIONS:     Large  dilated  stomach. 
OPERATIVE  FINDINGS:     No  operation. 

A  Antrum. 
B  Pylorus. 
C     First  portion  of  the  duodenum. 


Figure  31 

PATIENT  —  POSITION:     Man,  age  43.     Prone. 
ROENTGEN  CONCLUSIONS:     Normal  stomach. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A    Antrum  of  stomach. 

B     Pylorus. 

C     First  portion  of  duodenum. 

Note  the  pressure  of  the  first  portion  of  the  duodenum  against  the  antrum  of  the  stomach. 

This  was  considered  at  first  pathological  but  with  subsequent  plates  and  a  change  in  position  of  the  patient 

this  apparent  defect  disappeared. 


Figure  32 

The  same  case  as  Figure  3L 

This  shows  a  complete  filling  of  the  antrum  of  the  stomach  and  first  portion  of  the  duodenum  owing  to  the 

changed  position  of  the  patient. 

A     Antrum  of  stomach. 

B     First  portion  of  duodenum. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


29 


FIGURE  30 


FIGURE  31 


FIGURE  32 


30  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  33 

PATIENT  —  POSITION:     Woman,   age  32.     Prone. 

ROENTGEN  CONCLUSIONS:     Normal  stomach.      Dilatation  and  ptosis. 

OPERATIVE  FINDINGS:     No  operation. 

This  plate  illustrates  the  pressure  defect  of  the  ascending  colon  upon  the  greater  curvature  of  the  stomach. 
It  sometimes  becomes  verj^  confusing  to  differentiate  between  involvement  of  the  stomach  wall  and  the 
effect  of  pressure  due  to  the  large  intestine. 
A     Effect  of  pressure. 


Figure  34 

PATIENT  — POSITION:     Man,  age  47.     Prone. 

ROENTGEN  CONCLUSIONS:     Hypernephroma  causing   a  pressure   effect  on   a  normal  stomach. 

OPERATIVE  FINDINGS:     Hypernephroma  of  the  kidney. 

The  plates  show  displacement  of  the  stomach  to  the  right  Ijy  a  large  tumor  mass  on  the  left  side  which  was 

diagnosed  bj"  the  Roentgen  method  as  probable  hj-pernephroma. 

Note  the  displacement  of  all  the  abdominal  contents  bismuth  filled  to  the  right. 

A     Upper  boundaries. 

B     Lower  boundaries. 

C     Pressure  due  to  the  mass. 


Figure  35 
PATIENT  — POSITION:     Man,  age  40.     Prone. 

ROENTGEN  CONCLUSIONS:     Retroperitoneal  tumor.     Possible  gumma. 
OPERATIVE  FINDINGS:     Hypernephroma. 

Note  the  displacement  of  the  stomach  upwards  to  the  right  as  well  as  the  jejunum  and  ileum. 
A    Pressure  of  mass  on  greater  curvature  of  the  stomach. 
B     Outline  of  mass  against  jejunum. 
C    Jejunum. 
D     Ilemn. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


31 


FIGURE  33 


FIGURE  34 


FIGURE  35 


32  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


SECTION  II 

GASTRIC   ULCER 

Definition  —  Technique  —  Normal  Gastric  Shadow  —  Variations  from  the  Normal  — 
Positive  Signs  of  Ulcer  —  Presumptive   Signs  of  Ulcer 

The  lesion  commonly  known  as  gastric  or  peptic  ulcer  is  a  circumscribed  area,  varjang 
in  size  from  a  pinhead  to  half  a  dollar.  It  is  usually  situated  near  the  pylorus  and,  with 
few  exceptions,  involves  either  the  lesser  curvature  or  posterior  wall.  This  lesion  is  char- 
acterized by  a  loss  of  tissue  involving  the  mucosa  and  frequently  the  deeper  layers.  These 
ulcers,  which  clinicallj^  and  pathologically  are  distinct  from  "erosions,"  tubercular,  syphilitic 
and  various  traumatic  ulcerations  of  the  stomach  wall,  show  little  tendency  to  healing. 
Consequently  all  gastric  ulcers  become  "chronic"  ulcers  before  healing  takes  place. 

Shortly  after  the  onset  of  an  ulcer,  nature  attempts  repair.  The  result  is  a  disposition 
of  chronic  inflammatorj'  tissue  in  and  about  the  lesion.  This  inflammatorj'  reaction  within 
a  few  weeks  may  become  a  palpable  induration,  which  in  turn  causes  more  or  less  deformity 
in  the  stomach  wall. 

It  is  the  demonstration  of  the  presence  of  this  deformity  that  permits  us  to  make  a 
positive  Roentgen  diagnosis  of  gastric  ulcer.  The  ease  and  accuracy  with  which  the  diag- 
nosis is  made  varies  directly  with  the  degree  of  deformity.  In  so  far  as  chronic  gastric  ulcer 
is  concerned  we  rely,  as  in  the  case  of  duodenal  ulcer,  on  the  direct  method;  namely,  the 
exhibition  on  the  Roentgen  plate  of  the  actual  anatomical  defect. 

Technique.  For  the  demonstration  of  gastric  ulcer  we  use  the  same  meal  previously 
described;  in  brief,  two  ounces  of  bismuth  subcarbonate  or  the  speciall}''  prepared  barium 
sulphate  to  two  glasses  of  buttermilk,  amounting  to  one  pint.  This  is  taken  on  an  empty 
stomach. 

While  we  appreciate  the  value  of  the  Roentgenoscope  in  competent  hands,  and,  in  fact, 
all  our  patients  are  examined  in  this  way,  still  in  the  last  analysis  it  is  the  serial  plate 
upon  which  we  rely  for  our  diagnosis.  In  the  first  place,  the  problem  of  gastric  ulcer  in  a 
large  measure  is  a  study  of  detail.  We  look  for  minute  changes  and  slight  irregularities  in 
the  bismuth  outline.  These  can  be  seen  with  greater  accuracj^  and  ease  on  the  plate  than 
on  the  fluorescent  screen. 

Then  again,  in  the  plate  we  have  a  permanent  record,  while  with  the  screen  our  opinion 
has  to  be  based  on  an  uncertain  remembrance  of  a  passing  vision.  Without  doubt  the 
screen  is  of  great  value  in  demonstrating  motion  and  is,  therefore,  our  greatest  aid  in  show- 
ing abnormalities  of  gastric  phj'Siolog^'.  But  such  abnormalities,  at  best,  interest  us  only 
when  considering  the  presumptive  or  indirect  evidence  of  gastric  ulcer. 

Repeated  or  serial  plates  are  essential  to  demonstrate  the  permanency  of  a  shadow. 
A  typical  hour-glass  appearance,  for  example,  may  be  seen  on  two  or  three  plates,  but  on 
the  fourth  plate  we  may  get  the  shadow  of  a  normal  stomach.  In  the  demonstration  of 
the  constancy  of  large  defects,  the  Roentgenoscope  serves  well  and  is,  to  be  sure,  a  saving 
in  plates  and  time. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS  33 

As  for  the  best  position  in  which  to  take  plates,  we  find  the  ordinary  anteroposterior 
position  the  most  useful,  the  patient  standing  with  the  plate  against  the  abdomen.  It  is  in 
this  position  that  ulcers  are  hkely  to  show,  for  the  reason  that  seventy-five  to  eighty  per 
cent  occur  on  the  lesser  curvature  of  the  stomach.  In  the  upright,  anteroposterior  position 
the  lesser  curvature  is  brought  into  profile.  However,  in  this  position  there  is  often  diffi- 
culty in  filling  out  the  antrum.  In  such  a  case  an  anteroposterior  plate  with  the  patient 
prone  will  remedy  this  difficulty. 

Twenty  to  twenty-five  per  cent  of  gastric  ulcers  occur  on  the  posterior  wall.  These 
ulcers  are  frequently  shown  to  a  better  advantage  by  taking  the  plate  with  the  patient  in 
the  lateral  position,  either  standing  or  lying,  the  plate  against  the  patient's  right  side. 
Each  patient  is  an  individual  problem  and  the  plates  must  be  taken  as  the  needs  of  the 
case  indicate. 

This  is  of  special  importance  in  considering  the  interval  between  plates  and  the  num- 
ber of  times  a  patient  should  be  examined  by  the  Roentgenologist.  In  general,  a  patient 
should  be  studied  by  the  Roentgenoscope  while  taking  the  bismuth  meal  and  serial  plates 
made  immediately  after  and  again  at  six  and  twenty-four  hours. 

The  Positive  (or  Direct)  Evidence  of  Gastric  Ulcer.  The  following  five  varia- 
tions from  the  normal  gastric  bismuth  shadow  are  of  fundamental  importance  in  the  diag- 
nosis of  peptic  ulcer  and  appearing  singly  or  associated  they  are  nearly  pathognomonic 
of  this  lesion. 

A     Bismuth  in  the  ulcer  crater. 

B     Passage  of  bismuth  through  the  gastric  wall  due  to  a  chronic  perforation. 

C     Defect  in  the  bismuth  shadow  from  induration  in  the  gastric  wall. 

D    Permanent  hour  glass. 

E     Pyloric  obstruction,  other  than  from  new  growth. 

Demonstration  of  the  Ulcer  Crater.  Plates  taken  in  the  ordinary  anteroposterior 
position,  either  standing  or  lying,  bring  into  profile  the  lesser  and  greater  curvature.  Any 
break  in  the  outline  of  the  curvatures  will  be  detected  at  once.  Frequently  a  small  speck 
of  bismuth  can  be  seen  apparently  exuding  from  the  main  bismuth  shadow.  This  represents 
bismuth  actually  in  the  crater  of  the  ulcer.    This  is  unquestionably  pathognomonic  of  ulcer. 

Only  when  the  ulcer  is  in  profile  can  its  crater  be  shown  in  this  way.  Even  though 
eighty  per  cent  occur  on  the  lesser  curvature  and  are  naturally  thrown  into  profile  in  the 
anteroposterior  position,  still  the  crater  is  likely  to  be  filled  with  secretions  or  food  debris 
that  the  bismuth  may  not  penetrate. 

Demonstration  of  Chronic  Perforating  Ulcers.  Occasionally  ulceration  proceeds 
so  far  that  there  is  actual  perforation  of  the  gastric  wall.  The  Roentgen  picture  of  the 
chronic  perforated  ulcer  is  characteristic.  It  merely  represents  a  stage  later  than  the  simple 
ulcer.  The  picture  of  the  perforated  ulcer  shows  bismuth  actually  outside  the  stomach  wall, 
confined  in  a  small  sack  or  pouch.  This  sack  is  formed  by  walls  of  connective  tissue.  It 
is  the  result  of  nature's  endeavor  to  heal  and  prevent  the  impending  perforation.  The 
pouch  may  vary  from  the  size  of  a  pea  to  that  of  a  walnut.  UsuaUj^  there  can  be  seen  the 
thread-like  isthmus  connecting  the  pouch  with  the  stomach.  Along  with  the  bismuth,  the 
pouch  may  contain  a  gas  bubble.  It  is  frequently  noted  that  the  bismuth  in  the  pouch  will 
be  retained  long  after  the  stomach  is  empty.  This  condition  is  also  favorable  for  demon- 
stration in  the  ordinary  anteroposterior  position  from  the  fact  that  perforations  almost 
invariably  occur  on  the  lesser  curvature. 

Demonstration  of  Area  of  Induration.  While  in  many  cases  we  cannot  demon- 
strate the  ulcer  itself,  we  can,  however,  demonstrate  the  area  of  induration  about  the  ulcer. 


34  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 

This  area  of  induration  produces  a  local  rigidity  in  the  stomach  wall.  It  is  this  local  rigidity, 
or  lack  of  flexibility,  which  we  demonstrate  on  the  plate.  The  taking  of  several  plates  is 
important.  On  the  several  plates  will  be  seen  an  area,  usually  on  the  lesser  curvature, 
half  an  inch  to  two  inches  in  diameter,  over  which  there  is  no  evidence  of  peristaltic  waves. 
Sometimes  repeated  exposures  at  one-quarter  second  intervals  on  the  same  plate  with  the 
position  of  the  patient  unchanged  will  demonstrate  this  condition.  Such  a  plate  shows  a 
blurred  outline  of  the  stomach,  save  over  the  area  where  there  is  no  movement.  This 
localized  area  of  rigidity  indicates  pathology  involving  the  stomach  wall.  We  have  here 
found  the  Roentgenoscope  and  palpation  useful  in  checking  up  the  Roentgenograms. 

The  question  may  be  asked,  does  an  indurated  area  such  as  this  occur  only  in  chronic 
ulcer?  Theoretically,  no,  but  for  practical  purposes,  yes.  It  is  conceivable  that  a  new 
growth  might  give  a  similar  picture,  but  it  is  not  the  characteristic  picture  of  new  growth, 
as  we  shall  show  later.  And  further,  a  chronic  ulcer  showing  this  induration  will  invariably 
present  one  or  more  characteristic  signs  of  ulcer. 

In  addition  to  rigidity,  the  indurated  area  may  produce  a  filling  defect  causing  an  ir- 
regularity in  the  gastric  shadow.  This  irregularity  simply  means  infiltration  and  of  itself  is 
not  characteristic  of  ulcer. 

Demonstration  of  Organic  Hour-Glass  Deformity.  The  organic  hour  glass  must 
be  differentiated  from  the  functional  or  spasmodic  hour  glass.  Repeated  plates  are  usually 
sufficient  to  rule  out  spasmodic  hour  glass.  Then  again,  the  Roentgenoscope  and  palpation 
can  show  whether  or  not  the  contraction  is  permanent.  In  doubtful  cases  the  administra- 
tion of  atropine  will  relax  the  spasmodic  hour  glass. 

The  organic  hour  glass  is  practically  pathognomonic  of  chronic  ulcer.  Actual  irritation 
from  the  ulcer  produces  spasm  of  the  circular  muscle  fibres  in  the  plane  of  the  ulcer.  Later, 
there  is  undoubtedly  stiffening  or  actual  infiltration  in  the  fibres,  making  the  contraction 
rigid  or  permanent. 

The  exceptions  are  rare  cases  of  hour-glass  deformitj^  due  to  new  growth  and  adhesions. 
But,  as  Crane  has  pointed  out,  the  hour  glass  caused  by  new  growth  has  certain  character- 
istics which  help  to  differentiate  it  from  the  hour  glass  of  chronic  ulcer. 

The  hour  glass  of  new  growth  usually  presents  a  funnel-like  form,  while  that  of  chronic 
ulcer  is  sacculated.  The  sulcus  in  new  growth  is  likely  to  be  broad  and  irregular,  while 
that  of  ulcer  is  band-like  and  smooth  in  outline.  The  connecting  isthmus  in  the  hour  glass 
from  ulcer  is  eccentric,  usually  being  a  part  of  the  lesser  curvature,  while  the  isthmus  in 
malignant  hour  glass  is  in  the  center,  producing  a  sjTnmetrical  annular  defect  in  the  gastric 
shadow. 

Rarely  indeed  do  adhesions  produce  an  appearance  simulating  hour  glass.  Occasionallj- 
post-operative  adhesions  will  tie  the  stomach  to  the  abdominal  wall  at  the  site  of  the  inci- 
sion, which  may  produce  an  hour-glass  appearance.  It  is  possible  that  mesenteric  bands  may 
also  distort  the  stomach  in  such  a  way  as  to  suggest  a  constriction. 

Demonstration  of  Pyloric  Obstruction.  The  normal  stomach  with  our  meal 
empties  within  six  hours.  However,  we  do  not  laj'  much  stress  on  any  gastric  residue  under 
twelve  hours.  Certainly  an  eighteen  to  twenty-four  hour  residue  means  organic  stenosis  at 
the   pylorus.     We   have  never  seen  spasm  or  simple  atony  produce  twenty-four  hour  stasis. 

Benign  cicatrix,  new  growth  and  adhesions  are  the  three  causes  of  pyloric  obstruction. 

Benign  cicatrix  or  chronic  ulcer,  in  the  majority  of  cases,  has  its  own  characteristic 
picture.  First,  it  is  of  long  standing  and  therefore  is  associated  with  a  secondarj^  dilatation 
and  hypertrophy  of  the  stomach.  Violent  peristaltic  waves  suggest  chronic  ulcer.  Obstruc- 
tion from  new  growth  is  of  short  duration  and  is  associated  with  a  small  stomach. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS  35 

Careful  study  of  the  pyloric  region  in  the  different  positions  mil  usually  show  the 
characteristic  deformity  of  cancer.  As  is  discussed  elsewhere,  the  deformity  of  cancer  is 
quite  pathognomonic,  being  an  inroad  on  the  gastric  shadow  and  usually  annular. 

The  Peesumpti"ve  (or  Indirect)  Evidenxe  of  Gastric  Ulcer.  We  believe  that 
every  case  of  gastric  ulcer,  if  carefully  studied  in  the  way  that  has  been  suggested,  mil 
always  give  some  positive  evidence  of  its  presence.  However,  we  realize  full  well  that  it 
is  on  the  chronicity  of  the  ulcer  that  the  accuracy  of  the  diagnosis  depends.  And  it  is 
reasonable  to  suppose  that  there  may  be  certain  acute  ulcers  of  such  recent  origin  that  there 
has  been  insufficient  time  to  produce  any  appreciable  deforming  induration.  We  are  led  to 
suspect  the  presence  of  such  ulcers  by  certain  presumptive  or  indirect  e\ddence.  And  we 
emphasize  the  word  "suspect,"  for  this  e\ddence  is  indeed  far  from  being  pathognomonic. 

Spasm  of  the  pyloric  sphincter  is  indicated  by  a  greater  or  less  period  of  delay  before 
the  stomach  begins  to  empty.  The  normal  stomach  begins  to  empty  immediately  on  tak- 
ing the  meal.  This  delayed  relaxation  of  the  pyloric  sphincter  results  in  a  delayed  emptying 
of  the  stomach,  so  that  an  eight  to  ten-hour  gastric  residue  is  worthy  of  note. 

Spasm  of  the  circular  fibres  in  other  parts  of  the  stomach  is  shown  on  the  plate  as 
an  incisura,  usually  on  the  greater  curvature.  These  indentations  are  more  or  less  persistent 
and  the  greater  their  persistency,  the  more  valuable  they  are  as  evidence.  Without  much 
doubt  most  acute  gastric  ulcers  are  accompanied  by  a  certain  amount  of  spasm  of  the  circu- 
lar fibres  lying  in  the  same  plane  as  the  ulcer.  The  Roentgen  picture  is  simply  that  of 
an  indentation  on  the  greater  curvature  opposite  the  site  of  the  ulcer.  It  must  be  borne  in 
mind  that  these  incisurse  may  be  produced  reflexly  from  any  lesion  throughout  the  gastro- 
intestinal tract.    They  may  also  be  produced  by  various  drugs  and  even  by  nervousness. 

An  extreme  spasm  may  produce  such  a  marked  incisura  that  the  stomach  assumes  an 
hour-glass  appearance.  This  spasmodic  hour-glass  condition  means  nothing  more  than  a 
simple  incisura  and  must  not  be  confused  with  the  organic  hour-glass  deformity.  As  is 
mentioned  elsewhere,  the  administration  of  atropine  mil  easily  differentiate  spasm  from 
organic  deformity. 

In  our  experience  the  various  abnormalities  in  peristalsis  or  abnormal  conditions  of 
gastric  tone  bear  no  certain  relation  to  the  presence  or  absence  of  acute  gastric  ulcer. 

Also  in  our  experience,  a  tender-point  over  the  gastric  shadow,  demonstrated  by  Roent- 
genoscopic  palpation,  bears  no  relation  to  the  presence  or  absence  of  ulcer. 


36  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


GASTRIC   ULCER 


Figure  36 

PATIENT  — POSITION:     Woman,  age  28.     Prone. 

ROENTGEN  CONCLUSIONS:     Obstruction  of  oesophagus  due  to  ulcer  at  cardia,  possible  cardio-spasm. 

OPERATIVE  FINDINGS:     Passage  of  bougie  and  subsequent  history  suggest  ulcer  as  a  cause  rather  than 
spasm  alone. 

A    Dilatation  of  oesophagus  at  cardia. 

B     Obstruction  at  cardia. 

All  plates  showed  a  marked  filling  defect  in  cardia  of  stomach. 


Figure  37 

PATIENT  — POSITION:     Woman,  age  30.     Prone. 
ROENTGEN  CONCLUSIONS:     Gastric  ulcer. 
OPERATIVE  FINDINGS:     Confirmatory. 

A     Incisura  on  greater  curvature. 

Note  the  sharply  defined  area  of  induration  on  lesser  curvature.     This  plate  is  characteristic  of  a  large 

gastric  ulcer  high  up  on  the  lesser  curvature. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


37 


FIGURE  36 


FIGURE  37 


38  THE  ROENTGEN   DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  38 

Same  case  as  Figure  37. 

POSITION:     Upright. 

A    Shows  incisura  to  be  an  actual  involvement  of  the  stomach  rather  than  simple  spasm. 


Figure  39 

PATIENT  — POSITION:     Woman,  age  30.     Prone. 

ROENTGEN  CONCLUSIONS:  Chronic  ulcer  with  hour-glass  constriction.     Penetrating  ulcer  high  on  lesser 

curvature. 
OPERATIVE  FINDINGS:     Two  ulcers  on  lesser  curvature,  posterior  wall,  a  chronic  indurated  ulcer,  and 

a  small  ulcer  of  perforating  or  penetrating  type. 

A    Hour-glass  constriction  from  old  ulcer. 

B     Small  perforating  ulcer  on  lesser  curvature. 


Figure  40 

PATIENT  — POSITION:     Woman,  age  33.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer,  posterior  wall,  and  lesser  curvature. 

OPERATIVE  FINDINGS:     Large  florid  ulcer  on  posterior  wall,  lesser  curvature. 

A     Incisura  from  old  chronic  ulcer. 
B     Antrum  of  stomach  poorly  filled. 


Figure  41 

PATIENT  —  POSITION:     Woman,  age  34.     Prone. 

ROENTGEN  CONCLUSIONS:      Chronic  gastric  ulcer  causing  hour-glass  constriction  with  small  perforating 

ulcer  high  in  stomach. 
OPERATIVE  FINDINGS:     Marked  hour-glass  constriction   with    small  recent   ulcer  on   lesser  curvature. 

Adhesions  about  pylorus. 

A     Hour-glass  formation. 

Note  the  contraction  of  scar  tissue.     In  this  case  it  is  almost  identical  with  ulcer  higher  on  lesser  curvature. 

(Figure  39.) 

B     Similar  to  Figure  39,  except  that  this  case  is  undoubtedly  more  chronic. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


39 


FIGURE  38 


FIGURE  40 


FIGURE  39 


FIGURE  41 


40  THE  ROENTGEN   DIAGNOSIS  OF   SURGICAL  LESIONS 


Figure  42 

PATIENT  —  POSITION:     Woman,  age  33.     Prone. 

ROENTGEN  CONCLUSIONS:     Hour-glass  formation  due  to  chronic  ulcer  of  stomach  on  lesser  curvature. 

OPERATIVE    FINDINGS:     Large  chronic  ulcer  on  lesser  curvature,  posterior  wall. 

A     Incisura  due  partly  to  spasm,  and  partly  to  actual  contraction  of  the  wall. 

B     Note  the  effect  of  the  rigid  stomach  wall.     In  a  series  of  plates  this  straight  hne  contour  is  constant. 


Figure  43 

PATIENT  —  POSITION:     Woman,  age  31.     Prone. 

ROENTGEN  CONCLUSIONS:  Chronic  gastric  ulcer  with  small  ulcer  on  lesser  curvature,  beginning  per- 
foration. 

OPERATIVE  FINDINGS:  Large  indurated  ulcer  on  lesser  curvature,  posterior  wall.  Small  perforating 
ulcer  on  lesser  curvature. 

A    Contraction  of  stomach  due  to  ulcer. 

B     Area  sho\Adng  outcropping  of  bismuth,  suggestive  of  perforation. 


Figure  44 

PATIENT  — POSITION:     Woman,  age  39.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic   gastric   ulcer   with   complete   hour-glass   formation.      Perforating 

ulcer  on  lesser  curvature. 
OPERATIVE  FINDINGS:     Hour-glass  formation  with  almost  complete  stenosis  of  pars  media  of  stomach. 

In  this  mass  of  inflamed  tissue  the  "  saddle  back  "  type  of  ulcer  is  seen. 

A — B     Note  almost  complete  obUteration  of  stomach. 

C     Perforating  ulcer.     At  times  during  the  examination  this  area  showed  a  Haudek  niche. 


Figure  45 

PATIENT  — POSITION:     Man,  age  36.     Prone. 

ROENTGEN  CONCLUSIONS:     Hour-glass  formation  with  stenosis  of  whole  of  pars  media  due  to  ulcer. 

possibly  beginning  degeneration. 
OPERATIVE  FINDINGS:     Chronic  gastric  ulcer  forming  hour  glass  of  stomach.     Many  adhesions  about 

stomach  and  duodenum.     Not  malignant. 

A     Hour-glass  formation  from  cicatrix  of  duodenal  ulcer. 

B     Extent  of  ulcers. 

C    Dilatation  of  duodenum. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


41 


FIGURE  42 


FIGURE  43 


FIGURE  45 


42  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  46 

PATIENT  — POSITION:     Woman,  age  42.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer  with  probable  beginning  new  growth  in  antrum  of 

stomach. 
OPERATIVE    FINDINGS:      Chronic  gastric  ulcer,  posterior  wall,  lesser  curvature.      Extensive  adhesions 

about  duodenum  and  antrum.     No  evidence  of  new  growth. 

A     Incisura,  mostly  due  to  spasm. 

B     Filling  defect  suggestive  of  infiltrating  carcinoma. 


Figure  47 
Artist's  drawing  of  same  case  as  Figure  46. 


Figure  48 

PATIENT  — POSITION:     Man,  age  38.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer. 

OPERATIVE  FINDINGS:     Stomach  externally  appeared  normal.     On  opening  stomach  a  redundancy  of 
mucous  membrane  was  found  with  actual  stenosis. 

A  This  case  illustrates  a  rare  condition  found  in  only  one  case  of  the  writers'  series,  and  seen  in  one  other 
case  operated  upon  at  the  Carney  Hospital,  Boston.  The  only  differential  point  suggested  between 
chronic  indurated  ulcer  and  this  condition  is  that  with  involvement  of  the  mucous  membrane  alone  a 
perfectly  uniform  contraction  is  seen  in  the  Roentgenogram. 


Figure  49 

PATIENT  — POSITION:     Man,  age  53.     Prone. 

ROENTGEN  CONCLUSIONS :     Chronic  ulcer  on  lesser  curvature  perforating  at  time  of  bismuth  examination. 

OPERATIVE  FINDINGS:     The  lesser  peritoneal  cavity  was  found  at  operation  to  be  mostly  filled  with 
chronic  inflammatory  tissue. 

A     Ulcer  on  lesser  curvature. 

It  \\"ill  be  noted  that  the  ulcer  is  perforated.  Bismuth  is  seen  passing  out  as  though  ejected  by  a  hypo- 
dermic needle.  Perforation  was  not  proven  absolutely  at  time  of  operation  on  account  of  marked 
inflammatorj^  changes  found,  but  strongly  corroborated. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


43 


FIGURE  46 


FIGURE  47 


FIGURE  48 


FIGURE  49 


44  THE  ROENTGEN  DIAGNOSIS   OF   SURGICAL  LESIONS 


Figure  50 

PATIENT  —  POSITION:     Woman,  age  39.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  perforation  on  lesser  curvature  of  stomach  due  to  old  ulcer. 
OPERATIVE  FINDINGS:     Large   perforating   ulcer   found    on    lesser    curvature    adherent    and    involving 
pancreas. 

A     Perforating  ulcer  which  filled  mth  and  emptied  itself  of  bismuth  throughout  the  examination. 


Figure  51 

PATIENT  — POSITION:     Man,  age  41.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  stomach. 

OPERATIVE  FINDINGS:     Chronic  gastric  ulcer  on  the  lesser  curvature  of  the  stomach,  posterior  wall. 

A     Induration  and  contraction  of  the  stomach  wall  due  to  ulcer. 


Figure  52 

PATIENT  — POSITION:     Woman,  age  43.     Prone. 
ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer. 
OPERATIVE  FINDINGS:     Chronic  gastric  ulcer. 

A     Area  of  constriction  due  to  ulcer.     This  is  more  marked  than  one  would  expect  from  the  size  of  the 
ulcer  found  at  operation. 


THE  ROEXTGEX   DIAGNOSIS   OF  SURGICAL  LESIONS 


45 


FIGURE   SO 


FIGURE   51 


FIGURE  32 


46  THE  ROENTGEN   DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  53 

PATIENT  —  POSITION:     Woman,  age  50.     Prone. 

ROENTGEN  CONCLUSIONS:     Hour-glass  type  of  stomach  due  to  chronic  gastric  ulcer. 
OPERATIVE  FINDINGS:     Chronic  gastric  ulcer.     Almost  complete  obliteration  of  the  lumen.     Ulcer  of 
the  duodenum. 

A     Hour-glass  formation  clue  to  ulcer. 

B     Dilatation  of  antrum  due  to  an  obliterative  and  obstructive  type  of  duodenal  ulcer. 


Figure  54 


Same  case  as  Figure  53.     Lateral  view. 
A    Anterior  wall  of  stomach. 
B     Posterior  wall  of  stomach . 
C     Second  portion  of  duodenum. 


Figure  55 


PATIENT  —  POSITION:     Man,  age  53.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer  with  hour-glass  formation. 

OPERATIVE  FINDINGS:     Chronic  gastric  ulcer  probably  mahgnant  in  character.     Adhesions. 

A    Hour-glass  formation  due  to  ulcer. 

The  writers  found  nothing  to  suggest  malignancy,  but  the  subsequent  clinical  history  apparently  con- 
firms the  surgical  observations. 


Figure  56 

PATIENT  —  POSITION:     Man,  age  38.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer  with  adhesions  about  antrum  of  the  stomach.     Small 

perforating  ulcer  of  the  duodenum. 
OPERATIVE  FINDINGS:     Large    chronic   ulcer  of  stomach    on    lesser   curvature.     Extensive   adhesions. 

Small  ulcer  of  duodenum. 

A  Perforating  ulcer  on  lesser  curvature. 

B  Effect  of  adhesions. 

C  Pylorus. 

D  Perforating  ulcer  of  the  duodenum. 

Figure  56A 

See  colored  insert,  Plate  I. 


PLATE  I  — FIGURE  56A 


CHRONIC    GASTRIC    ULCER  WITH  ADHESIONS  ABOUT    ANTRUM  OF  THE 
STOMACH.     SMALL  PERFORATING  ULCER  OF  THE    DUODENUM 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


47 


FIGURE  S3 


FIGURE  54 


FIGURE  55 


48  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


Figure  57 

PATIENT  — POSITION:     Man,  age  41.     Standing. 

ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer  with  possible  adhesions. 

OPERATIVE  FINDINGS:     Chronic  gastric  ulcer.     Extensive  formation  of  adhesions. 

A     Effect  of  ulcer  deforming  antrum  of  stomach. 
B     Contracting  due  to  adhesions. 


Figure  58 

PATIENT  — POSITION:     Woman,  age  52.     Prone. 

ROENTGEN  CONCLUSIONS:     Hour-glass  formation  due  to  chronic  ulcer  primarily,  possibly  beginning 
degeneration. 

OPERATIVE  FINDINGS:      Chronic  gastric  ulcer  with  hour-glass  formation,  no  evidence  of  malignancy.     A 
small  ulcer  of  the  duodenum  noted. 

A     Hour-glass  formation  due  to  ulcer.     Filling  defect  seen  in  plate  and  malignancy  suggested  therefrom  due 

to  pressure  of  the  tail  of  the  pancreas  and  in  part  due  to  adhesions. 
No  Roentgen  evidence  of  the  duodenal  ulcer  found. 


Figure  59 

Artist's  drawing  made  at  time  of  operation. 


THE   ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


49 


FIGURE   57 


FIGURE   58 


FIGURE   59 


50  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  60 

PATIENT  — POSITION:     Woman,  age  48.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  antrum  of  stomach.     Possible  pathological  gall-bladder. 

OPERATIVE  FINDINGS:     Probable  chronic  gastric  ulcer.     Adhesions  so  extensive  about  gall-bladder  and 
stomach  as  to  make  detailed  inspection  of  stomach  impossible. 

A    Hour-glass  formation  at  antrum. 

B     Pylorus. 

C     Pressure  by  visualized  gall-bladder  on  duodenum. 


Figure  61 

Same  ease  as  Figure  60. 

A     Six-hour  plate  showing  residue  in  antrum  of  stomach  that  persisted  for  more  than  eighteen  hours. 


Figure  62 

PATIENT  — POSITION:     Man,  age  39.     Standing. 

ROENTGEN  CONCLUSIONS:     Ulcers  of  stomach,  at  pars  media,  and  near  pylorus  on  lesser  curvature. 

OPERATIVE  FINDINGS:     Chronic  gastric  ulcer  on  lesser  curvature,  small  ulcer  in  antrum  near  pylorus, 
and  an  ulcer  of  duodenum  extending  to  pylorus,  with  adhesions. 

A     Ulcer  on  lesser  curvature,  pars  media. 
B     Ulcer  on  lesser  curvature  near  pylorus. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


51 


52  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  63 

PATIENT  — POSITION:     Man,  age  61.     Standing. 

ROENTGEN  CONCLUSIONS:     Traumatic  hour-glass  stomach,  extensive  chronic  inflammatory  tissue. 

OPERATIVE  FINDINGS:     Hour-glass  stomach  due  to  inflammation  about  stomach. 

A     Narrowing  of  the  stomach  due  to  a  large  band  of  adhesions. 

B     Antrum  dilated,  which  is  due  to  moderate  obstruction  at  pylorus. 

C     Pylorus. 


Figure  64 

PATIENT  — POSITION:     Man,  age  52.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer. 

OPERATIVE  FINDINGS:     Chronic  ulcer  in  lesser  curvature  of  stomach. 


A    Deforming  effect  of  cicatrix  of  ulcer. 


Figure  65 

PATIENT  — POSITION:     Man,  age  63.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer  with  adhesions. 

OPERATIVE  FINDINGS:     Gastric  ulcer  of  antrum  with  extensive  adhesions. 

A     Effect  of  ulcer  and  adhesions  about  antrum  of  the  stomach. 
B     Deformity  of  pylorus  due  to  adhesions. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL 


LESIONS 


53 


FIGURE  64 


54  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  66 

PATIENT  — POSITION:     Man,  age  48.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer  near  pylorus,  possibly  malignant. 

OPERATIVE  FINDINGS:     Chronic  gastric  ulcer  of  stomach,  resected  but  no  evidence  of  malignancy. 

A    Effect  of  cicatrix. 

It  was  suspected  by  the  characteristic  deformity  that  there  was  possibly  a  beginning  degeneration. 


Figure  67 

PATIENT  — POSITION:     Man,  age  51.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer  with  small  tumor  mass. 

OPERATIVE  FINDINGS:     Chronic  gastric  ulcer  with  marked  contraction  of  stomach.     A  benign  tumor 
the  size  of  an  egg,  and  extragastric,  was  found. 

A    Pressure  on  stomach  due  to  effect  of  tumor. 
B    Narrowing  due  to  cicatrix  and  adhesions. 
C    Pylorus. 


Figure  68 

PATIENT  — POSITION:     Man,  age  43.     Prone. 

ROENTGEN  CONCLUSIONS:     Ulcer  near  pylorus  on  lesser  curvature. 

OPERATIVE  FINDINGS:     Chronic  gastric  ulcer  near  pylorus.     Marked  dilatation  of  first  portion  of  duo- 
denum.    Pathological  gall-bladder  with  adhesions. 

A    Deformity  of  antrum  due  to  ulcer. 

B     Constriction  due  to  ulcer. 

C     Pressure  of  gall-bladder  on  duodenum. 


THE   ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


55 


FIGURE   66 


FIGURE  68 


56  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  69 

PATIENT  ^POSITION:     Man,  age  53.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  at  pylorus. 

OPERATIVE  FINDINGS:     Extensive  adhesions  about  pylorus  and  antrum  of  stomach.     Small  ulcer  found 
near  pylorus  on  lesser  curvature. 

A    Series  of  plates  showed  rigidity  of  wall  of  stomach  at  this  point. 

B     Constriction  due  partly  to  adhesions  and  partly  to  contraction,  which  is  due  to  ulcer  on  lesser  curvature. 


Figure  70 

PATIENT  — POSITION:     Woman,  age  33.     Prone. 

ROENTGEN  CONCLUSIONS:     Small  ulcer  on  lesser  curvature. 

OPERATIVE  FINDINGS:     Six   months    after    Roentgen    examination    operation    revealed    a    large    ulcer 
on  lesser  curvature,  posterior  wall. 

A     Incisura  on  greater  curvature. 

B    Area  on  lesser  curvature  due  to  ulcer. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


57 


58  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


Figure  71 

PATIENT       POSITION:     Man,  age  52.     Prone. 

ROENTGEN  CONCLUSIONS;     Small  perforating  ulcer  on  lesser  curvature.     Ulcer  near  pylorus  on  lesser 
curvature.     One  on  greater  curvature  near  pylorus.     Duodenal  ulcer. 

OPERATIVE  FINDINGS:     Roentgen  findings  confirmed  in  detail.     (See  artist's  drawing,  Figure  72.) 

A  Perforating  ulcer,  lesser  curvature,  posterior  wall,  positively  demonstrated  on  lateral  plate. 

B  Ulcer  on  greater  curvature. 

C  Ulcer  on  lesser  curvature,  near  pylorus. 

D  Ulcer  of  duodenum  on  inferior  border. 


Figure  72 


Artist's  dra\ving.      Same  case  as  Figure  71. 
Arrows  point  to  lesions  found  at  operation. 


THE  ROENTGEN   DIAGNOSIS  OF  SURGICAL  LESIONS 


59 


FIGURE  71 


60  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  73 

PATIENT  —  POSITION:     Woman,  age  38.     Upright. 
ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer  near  pylorus. 
OPERATIVE  FINDINGS:     Confirmatory. 

A     Ulcer  at  pylorus  on  lesser  curvature. 

Note  that  the  deformity,  due  to  connective  tissue,  in  antrum  and  about  pylorus,  is  constant  both  in  the 

upright  and  the  prone  position. 


Figure  74 
Same  case  as  Figure  73,  taken  prone,  which  reproduces  accurately  the  size  and  detail  of  ulcer. 

Figure  75 

Same  case  as  Figures  73  and  74,  after  resection  of  stomach. 
A     Lesser  curvature. 
B     Ostium. 


THE   ROEXTGEX   DIAGXOSIS   OF   SURGICAL   LESIOXj 


61 


FIGURE    73 


FIGURE    74 


62  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  76 

PATIENT  — POSITION:     Man,  age  50.     Prone. 

ROENTGEN  CONCLUSIONS:     Pyloric  obstruction  due  to  ulcer  of  duodenum  or  pylorus  or  both. 

OPERATIVE  FINDINGS:     Ulcer  of  pylorus  causing  obstruction. 

A     Note  the  dilatation  of  antrum,  the  so-called  prognathion  dilatation  characteristic  of  pyloric  obstruction. 


Figure  77 

PATIENT  — POSITION:     Man,  age  49.     Prone. 
ROENTGEN  CONCLUSIONS:     Ulcer  in  antrum  near  pylorus. 
OPERATIVE  FINDINGS:     Chronic  ulcer  in  antrum  of  stomach. 

A    Ulcer. 

Note  sharp  incutting  along  lesser  curvature. 


Figure  78 
Same  case  as  Figure  77,  standing. 

A     The  deformity  due  to  ulcer  is  even  more  distinct  than  in  prone  position. 
B     First  portion  of  the  duodenum  shomng  less  filling  defect. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


63 


FIGURE   76 


FIGURE   77 


FIGURE   78 


64  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figures  79,  80,  81  and  82 

PATIENT       POSITION:     Woman,  age  39.     Prone. 

ROENTGEN  CONCLUSIONS:     Small  gastric  ulcer  near  pylorus  on  lesser  curvature. 

OPERATIVE  FINDINGS:     Small  acute  ulcer  on  lesser  curvature. 

A    Defect  in  antrum  due  to  ulcer. 

Note :  In  this  series  of  four  plates  this  defect  is  constant  throughout. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


65 


FIGURE   79 


FIGURE  80 


FIGURE  81 


FIGURE  82 


66  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  83 

PATIENT  — POSITION:     Woman,  age  36.     Prone. 

ROENTGEN  CONCLUSIONS:     Gastric  ulcer  producing  hour-glass  type  of  stomach. 

OPERATIVE  FINDINGS:     Large  gastric  ulcer  on  the  lesser   curvature   of  the   stomach,    posterior   wall. 
Hour-glass  formation  due  to  scar  tissue. 

A    Hour  glass. 

B     Penetrating  ulcer  of  the  duodenum. 


Figure  83A 

PATIENT  — POSITION:     Woman,  age  45.     Prone. 

ROENTGEN  CONCLUSIONS:     Gastric  ulcer  near  pylorus  on  lesser  curvature. 

OPERATIVE  FINDINGS:     Gastric  ulcer. 

A    Gastric  ulcer. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


67 


FIGURE  83 


FIGURE    83A 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


SECTION  III 


GASTRIC  NEW  GROWTH 

Classification  —  Value  of  the  Roentgen  Ray  in  Diagnosis  and  Prognosis  —  Early 
Carcinoma  —  Advanced    Carcinoma    with    Symptoms  —  and    without 
Symptoms  —  Value  of  the  Negative  Plate 

The  routine  use  of  the  Roentgen  ray  in  the  diagnosis  of  gastric  cancer  has  now  come 
to  be  recognized  as  one  of  tlie  most  important  means  of  diagnosis. 

We  beheve  it  is  fair  to  state  that  the  newer  methods  of  chemical  examination  of  the 
stomach  contents,  such  as  the  glycltrj-ptophan  test  and  the  phosphotungstic  acid  reaction 
of  Wolff,  give  results  which  are  unstable  and  upon  which  no  firm  foundation  can  be  laid. 
The  same  is  true  of  the  present  status  of  the  serum  tests  for  cancer,  such  as  the  haemolysis 
test  and  the  modified  Abderhalden  reaction.  Even  if  positive,  the  latter  give  no  hint  of 
the  location  of  the  growth. 

In  short,  the  situation  at  the  present  time  as  regards  the  possibihty  of  making  a  reason- 
ably early  diagnosis  of  gastric  cancer  from  clinical  data  alone  is  practicalh'  hopeless. 
Smithies  of  Chicago,  in  a  paper  before  the  American  Association  of  Gastroenterologists, 
stated  that  there  was  no  one  dependable  sign  on  which  to  base  the  diagnosis.  All  this, 
however,  refers  to  the  usual  methods  of  gastro-intestinal  study. 

With  the  Roentgen  method,  on  the  other  hand,  we  have  a  means  at  our  disposal  which 
we  believe  has  already  shown  itself  to  be  of  distinct  value  in  detecting  early  carcinoma. 
It  is  not  to  be  inferred  that  the  method  is  todaj^  an  absolutely  positive  one,  or  that  every 
case  can  be  detected  in  its  incipiencj^;  but  we  do  Mash  to  state  emphatically  that  we  are 
alread}^  in  the  possession  of  certain  evidence  which  pushes  the  limits  of  diagnosis  much 
further  than  can  be  done  today  hj  any  other  methods  of  examination. 

The  Roentgen  diagnosis  of  gastric  carcinoma  can  be  classed  under  two  headings.  First, 
there  is  the  early  recognition  of  earl}'  cancer.  Secondly,  there  is  the  recognition  of  latent 
cancer,  which  is  usually  advanced  cancer  without  symptoms.  In  this  second  group  may 
also  be  included  those  cases  about  whose  diagnosis  there  is  no  doubt  clinically.  Such  cases 
are  usually  advanced  and  the  Roentgen  vay  is  useful  as  confirmator}'  evidence,  or  in  giving 
a  more  accurate  prognosis. 

The  Roentgen  examination  in  cases  of  this  second  group,  while  interesting  and  settling 
matters  for  the  patient,  does  not  help  much  because  this  type  of  case  is  not  early  enough 
to  give  hope  of  cure. 

The  recognition  of  early  cancer  is  the  diagnosis  that  is  of  real  value  both  to  the  patient 
and  to  the  surgeon.  In  this  instance  we  have  distinct  hopes  of  detecting  the  cancer  early 
enough  to  obtain  radical  cure  by  surgerj'.  This  is  the  type  of  lesion  which  gives  verj'  ob- 
scure and  few  gastric  sjTnptoms.  There  is  usually  no  obstruction,  the  acidity  maj^  be  practi- 
cally unchanged,  there  is,  of  course,  no  lactic  acid,  and  there  may  be  no  blood  in  the  gastric 
contents  or  stools.  The  data  upon  which  even  an  exploratory'  examination  could  be  advised 
are   therefore   slight. 

These  lesions  are  quite  small  and  are  situated  at  the  pylorus,  or  rather  just  pre-pyloric. 


THE   ROEXTGEX   DIAGNOSIS   OF   SURGICAL   LESIOXS  69 

They  may  be  primary  cancer,  or  the  result  of  malignant  degeneration  of  old  ulcer:  which 
in  the  ^Titers'  experience  is  most  common.  The  extension  of  the  gro^nh  is  from  the  pylorus 
and  is  not  anntilar  in  character. 

The  method  to  be  considered  in  the  Roentgen  examination  of  these  cases  is  extremely 
important.  The  Roentgenoscope,  while  of  some  value  in  this  connection,  shotild  by  no 
means  be  depended  upon  exclusively.  These  lesions  are  so  .small  that  their  direct  detection 
upon  the  Roentgenoscopic  screen  is,  in  the  majority  of  cases,  almost  impossible.  The  screen 
study  of  the  indirect  manifestations,  such  as  h^iDermotihty.  lack  of  peristalsis,  antiperistalsis, 
etc.,  while  important,  certainly  does  not  warrant  any  positive  cUagnosis.  and  is  apt  to 
lead  to  many  errors.  In  other  words,  a  diagnosis  of  carcinoma  of  the  stomach  made  by 
the  fluorescent  screen  is  usually  only  inferential  and  is  dangerotis.  The  chief  danger  is 
the  chance  of  missing  lesions  that  could  be  detected  by  other  methods  of  Roentgen  ex- 
amination. The  only  safe  and  exact  method  of  diagnosis  is  b}"  the  direct  demonstration 
of  the  lesion  upon  plates. 

The  techniciue  in  the  early  chagnosis  of  early  cancer  of  the  stomach  varies  in  no  essen- 
tial detail  from  the  routine  examination  for  other  gastric  lesions.  The  bismuth  stibcarbonate 
(or  bariima  substitute)  and  buttermilk  is  the  routine  meal.  Plates  are  made  at  once  follow- 
ing the  ingestion  of  the  meal.  The  patient  is  examined  in  both  the  standing  and  prone 
positions.  If  any  filling  defect  is  observed  plates  are  made  mth  the  patient  in  the  lateral 
position.  Repeated  or  serial  plates  are  essential  to  demonstrate  the  permanency  of  any 
defect.  It  must  always  be  borne  in  mind  that  even  one  plate  which  shows  a  normal  fiUing 
of  the  stomach  carries  more  weight  than  twenty  others  which  may  show  a  defect. 

The  Roentgen  picture  consists  of  a  filhng  defect  in  the  gastric  shadow.  This  defect 
in  the  early  case  is  small  and  is  usually  at  or  near  the  pylorus.  A  small  percentage  of 
these  primary  new  growths  occiu"  at  the  cardiac  end,  being  situated  usually  at  the  cardiac 
orifice.  Cases  in  this  group  are  detected  first  dm-ing  the  study  of  the  oesophagus,  obstruction 
at  the  cardia  being  their  most  common  manifestation.  Primary  carcinoma  in  the  pars  media 
is  comparatively  rare. 

These  filling  defects,  when  they  occiu-  near  the  pylorus,  are  annular  in  character,  resem- 
bling in  the  very  early  cases  a  greater  elongation  of  the  pyloric  gap.  This  annular  appear- 
ance is  the  fundamental  characteristic  which  distinguishes  these  lesions  from  the  ordinary 
chronic  ulcer  in  this  region. 

Just  why  these  lesions  should  give  this  annular  defect  we  are  not  at  present  ready 
to  state.  It  is  barely  possible  that  the  extension  of  the  cancer  cells  through  the  lower 
layers  of  the  stomach  wall  affects  the  contractihty  so  as  to  exaggerate  the  defect  and  give 
the  annular  appearance.    Of  course  this  is  only  suggestive. 

The  characteristic  defect  must  be  seen  on  a  number  of  plates,  although  not  neces- 
sarily a  large  niunber  of  plates.  It  is  advisable  to  confirm  the  presence  of  the  defect  at 
another  stomach  examination,  usuaUy  made  after  the  twent}"-four  hoiu'  plate.  It  is  especially 
important  to  show  the  defect  in  the  lateral  view  of  the  stomach,  as  this  disposes  definitely 
of  the  problem  of  pressiu-e  from  liver,  gaU-b ladder,  etc. 

Xext  in  importance  to  the  annular  character  of  the  le.sion  is  the  irregular  ■'bitten-out'" 
appearance.  This  is  seen  most  frequently  in  the  advanced  gro-n-ths,  but  should  be  searched 
for  even  in  the  smaUest  lesions.  An  annular  defect  associated  -n-ith  this  characteristic  ir- 
regularity is  pathognomonic  of  growth.  It  is  very  rarely  simulated  to  any  extent  by  chronic 
ulcer. 

Of  course  the  problem  of  mahgnant  degeneration  of  old  ulcer  is  always  present.  Om- 
observations  of  the  defects  in  this  region  have  led  us  to  the  conclusion  that  whenever  this 
irregular,   annular  defect  is  found  rachcal  surgery    should    be    urged.       By    this    we    mean 


70  THE  ROENTGEN   DIAGNOSIS  OF  SURGICAL  LESIONS 

resection  of  the  lesion  if  it  is  surgically  possible  and  not  a  mere  palliative  gastroenterostomy. 
Of  course  resection  will  depend  upon  the  mobihty  of  the  part,  lack  of  adhesions,  absence 
of  liver  metastases,  glands,  etc.  No  doubt  in  many  cases  the  possibiUty  of  cancer  is  of 
less  consequence  than  the  added  risk  of  resection.  These  lesions,  whether  actually  chronic 
ulcers  or  not,  as  far  as  treatment  is  concerned,  should  all  be  considered  new  growth. 

With  the  lesions,  however,  which  give  a  definite  Roentgen  sign  of  probable  or  possible 
mahgnancy,  we  beUeve  no  surgeon  has  the  moral  right  to  deny  his  patient  the  chance 
of  cure  that  is  afforded  by  resection.  The  decision  of  malignancy  should  not  be  allowed 
to  rest  with  the  surgeon  who  has  only  external  inspection  and  palpation  to  guide  him. 
The  Roentgenologist  has,  in  addition,  the  evidence  from  the  mucosal  side  of  the  stomach. 
The  sole  judge  of  the  case  should  be  the  pathologist  after  he  has  examined  the  microscopic 
sections  from  the  excised  lesion. 

We  beheve  these  observations  can  be  summarized  briefly.  The  best  chnicians  today 
are  agreed  that  the  early  diagnosis  of  gastric  carcinoma  is  hopeless  with  chnical  methods 
alone.  With  the  Roentgen  method  properly  applied,  we  are  sure  we  have  one  means  at  our 
disposal  that  will  enable  us  to  detect  the  cases  when  they  are  still  amenable  to  surgery. 
The  lesions  are  small  and  located  near  the  pylorus,  showing  small  filling  defects,  annular 
in  character.  With  such  findings  present,  the  Roentgenologist  should  urge  resection,  as 
only  in  this  way  can  the  diagnosis  be  helped  and  the  problem  of  gastric  cancer  be  solved. 

The  negative  aspect  has  not  been  emphasized  enough.  The  negative  Roentgen  plate 
is  today  of  as  much  value  in  diagnosis  as  the  plate  with  positive  evidence  of  disease.  This 
negative  value  depends  upon  only  one  important  factor;  that  is,  the  technique.  Investi- 
gators must  adhere  to  one  well-tried  technique  and  have  the  certainty  of  conclusive  evidence 
from  this  technique.  With  our  routine  every  normal  stomach  must  give  a  normal  Roentgen 
picture  and  no  normal  picture  will  be  obtained  if  the  stomach  contains  within  its  walls 
any  organic  changes.  A  normal  stomach  on  the  Roentgen  plate  absolutely  rules  out  any 
growth  beyond  the  microscopic  stage.  This  is  of  great  practical  benefit,  for  many  of  our 
patients  come  suffering  from  a  fear  of  cancer.  A  negative  gastro-intestinal  examination 
cures  the  sufferer. 

The  appearance  of  advanced  carcinoma  is  merely  a  more  extensive  and  pronounced 
picture  of  early  carcinoma.  The  elements  are  the  same.  First,  the  annular  deformity  may 
have  extended  so  far  that  instead  of  a  simple  elongation  of  the  pylorus,  we  now  have  marked 
canalization  involving  a  half  or  two-thirds  of  the  stomach.  Second,  the  irregular  outline, 
with  its  "bitten-out"  appearance,  now  assumes  an  appearance  of  finger-like  projections 
extending  into  the  body  of  the  bismuth  shadow. 

In  extreme  cases,  the  whole  stomach  may  be  involved  so  that  the  picture  shows  a 
rigid  tubular  canal  extending  the  whole  length  of  the  stomach.  This  canal  may  vary  in 
diameter  from  half  an  inch  to  two  or  three  inches.  In  the  latter  condition,  the  stomach 
has  been  described  as  a  "leather  bottle."  The  walls  are  absolutely  rigid,  due  to  the  neoplastic 
infiltration.  The  plates  show  no  evidence  of  peristaltic  waves  and,  under  the  screen,  its 
shape  is  not  affected  by  moderate  pressure  and  there  is  usually  an  accompanying  palpable 
tumor.  The  size  of  the  stomach,  in  such  a  condition,  is  usually  constant.  Its  walls  are 
no  longer  elastic  so  that  there  is  no  yielding  of  the  walls  when  the  patient  attempts  to 
eat.  The  patient  can  therefore  eat  only  a  small  amount  at  a  time,  even  with  the  very 
rapid  emptying  of  the  stomach  which  is  a  characteristic  feature.  The  writers  have  in  mind 
a  case  where  the  patient  could  take  only  half  the  meal.  A  plate  taken  within  one  minute 
after  the  last  swallow  showed  at  least  two-thirds  of  the  meal  to  be  in  the  small  intestine. 

These  advanced  cases  sometimes  show  an  hour-glass  deformity.  This  need  not  be 
confused  with  the  hour-glass  deformity  produced  by  chronic  ulcer.    In  ulcer,  the  outline 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS  71 

of  the  constricted  portion  is  smooth  and  the  sulcus  usually  narrow,  while  with  new  growth 
the  sulcus  is  broad  and  the  outline  irregular.  Furthermore,  the  connecting  isthmus  of  the 
hour-glass  deformity  in  ulcer  is  displaced  to  one  side.  Usually  it  corresponds  to  the  lesser 
curvature.  The  deformity  is  not  symmetrical.  With  new  growth,  however,  the  connecting 
isthmus  is  usually  central  and  the  hour-glass  deformity  is  quite  symmetrical.  This  de- 
formity in  chronic  ulcer  is  due  to  a  contraction  of  a  band  of  circular  muscle  fibres,  while 
in  new  growi;h  it  is  an  annular  infiltration  of  the  stomach  wall  with  new  tissue. 

A  few  cases  of  early  carcinoma  will  produce  early  symptoms.  This  occurs  when  the 
lesion  is  at  the  pylorus  and  there  is  produced  early  pyloric  obstruction.  Such  patients 
come  to  the  Roentgenologist  early  and  the  examination  shows  principally  a  gastric  stasis, 
with  more  or  less  deformity  about  the  pylorus.  These  cases  maj'  be  confused  with  obstruc- 
tion from  chronic  ulcer. 

However,  the  e\ddences  of  muscuJar  hypertrophy,  gigantic  peristalsis,  marked  enlarge- 
ment of  the  stomach,  etc.,  are  usually  found  with  chronic  ulcer  and  not  with  cancer,  prin- 
cipally because  obstruction  from  cancer  is  of  shorter  duration  and  these  secondare"  changes 
have  not  had  time  to  take  place.  The  history  may  be  of  great  value  in  helping  to  dif- 
ferentiate these  two  conditions,  chronic  ulcer  or  new  growth. 


72  THE  EOENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


GASTRIC  NEW  GROWTH 

Figure  84 

PATIENT— POSITION:     Woman,  age  25.     Prone. 

ROENTGEN  CONCLUSIONS:     Normal. 

OPERATIVE  FINDINGS:     Exploratory.     Stomach  and  duodenum  found  normal. 

Key  plate 

1  Region  of  cardia  distended  with  air. 

2  Pars  media. 

3  Pars  pylorica,  or  antrum. 

4  Pylorus  relaxed. 

5  First  portion  of  the  duodenum.  "  Bishop's  Cap."  Roentgenographically  the  first  portion  of  the 
duodenum  shows  the  superior  and  inferior  border  always  smooth  in  outline.  The  base,  or  pjdoric 
region,  is  also  smooth. 

6  Second  portioii  of  the  duodenum. 

Note  the  valvulee  coimiventes  which  distinguish  it  from  the  stomach  and  first  portion  of  the  duodenum. 
Histological^  the  stomach  and  first  portion  are  essentially  the  same. 

7  The  third,  or  transverse  portion,  of  the  duodenum.  This  passes  transversely  and  to  the  left  in  front 
of  the  vertebral  column  and  is  partly  obscured  by  the  stomach.  Note  at  the  junction  of  the  second 
and  third  portions  a  narrowing  which  is  physiological.  In  the  prone  position  this  is  partly  due  to 
pressure.     Note  the  tendency  of  the  duodenum  to  dilate  before  food  passes  this  point. 


Figure  85 

Artist's  dra^\ang  of  Case  86  —  Plate  II. 

Figure  86 

PATIENT  — POSITION:     Man,  age  58.     Prone. 

ROENTGEN  CONCLUSIONS:     Extensive  involvement  of  the  greater  and  lesser  curvatures  of  the  stomach 
due  to  gastric  new  growth.     Probable  adenocarcinoma. 

OPERATIVE  FINDINGS:     Inoperable  carcinoma  of  practically  the  entire  antrum  and  pars  media. 

A     Extension  of  growth  towards  cardia. 

B     Antrum. 

C     Pylorus. 

See  colored  drawing  made  at  time  of  operation.     (Plate  II.) 


PLATE  II— FIGURE  85 


EXTENSIVE    INVOLVEMENT    OF    THE    GREATER  AND    LESSER    CURVATURES 
OF  THE  STOMACH  DUE  TO   GASTRIC   NEW  GROWTH 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


73 


74  THE  ROENTGEN   DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  87 

PATIENT  — POSITION:     Man,  age  63.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer  at  the  pylorus  with  beginning  degeneration.     Probable 
early  carcinoma. 

OPERATIVE  FINDINGS:     Resection;   chronic  gastric   ulcer    at   pylorus.     Pathological  report,  adenocar- 
cinoma on  the  base  of  old  ulcer. 

A    Elongation  of  the  pylorus,  also  the  marked  annular  defect  which  is  characteristic  of  carcinoma  and 

not  of  ulcer. 
B     First  portion  of  duodenum,  normal. 
This  is  constant  throughout  a  series  of  plates,  in  the  prone,  lateral,  and  standing  positions. 


The  same  case  as  Figure  87. 
A    Defect  of  filling. 


The  same  case  as  Figures  87  and  : 
A     Defect  of  filling. 


Figure  88 


Figure  89 


Figure  90 


The  artist's    drawing  made  at  the  time  of  operation  from  the  resected    portion   of  the   stomach   and 
duodenum. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


75 


^^'■ 


w 


76  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  91 

PATIENT  —  POSITION:     Man,  age  53.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  with  beginning  degeneration.     Probable  carcinoma. 
OPERATIVE  FINDINGS:     Resection;  chronic  ulcer  at  the  pylorus.     Pathological  report,  chronic  ulcer, 
adenocarcinoma. 

A    Area  which  shows  definitely  the  annular  deformity,  characteristic  of  early  carcinoma. 
(See  Figures  87,  88  and  89.) 


Figure  92 

PATIENT  —  POSITION:     Woman,  age  34.     Prone. 
ROENTGEN  CONCLUSIONS:     Early  carcinoma  at  pylorus. 

OPERATIVE  FINDINGS:     Annular    growth    about   pylorus    and    antrum   of  the  stomach.     Pathological 
report,  adenocarcinoma. 

A     Characteristic  annular  defect. 
(See  Figures  87  and  91.) 

Figure  93 

PATIENT --POSITION:     Man,  age  38.     Prone. 

ROENTGEN  CONCLUSIONS:     Annular  carcinoma  at  pylorus. 

OPERATIVE  FINDINGS:     Chronic  ulcer.     Pathological  report,  adenocarcinoma. 

A     Characteristic  annular  defect  due  to  early  carcinoma. 

It  is  worthy  of  note  in  this  case  that  the  operating-  surgeon  would  not  have  performed  a  resection  of  the 

stomach  on  the  surgical  findings  but  was  influenced  solely  by  the  Roentgen  observations. 


Figure  94 

PATIENT  — POSITION:     Man,  age  52.     Prone. 

ROENTGEN  CONCLUSIONS:     Carcinoma  of  the  pylorus  and  antrum  of  the  stomach. 

OPERATIVE  FINDINGS:     Inoperable  carcinoma  of  the  stomach. 

A    Extent  of  growth  on  greater  and  lesser  curvature. 

Plate  made  five  minutes  after  the  bismuth  meal  shows  a  very  rapid  emptying  of  the  stomach. 


THE  ROENTGEN   DIAGNOSIS  OF  SURGICAL    LESIONS 


77 


FIGURE   91 


FIGURE   92 


FIGURE   93 


FIGURE   94 


78  THE  ROENTGEN   DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  95 

PATIENT  — POSITION:     Man,  age  53.     Prone. 
ROENTGEN  CONCLUSIONS:     Early  carcinoma  at  pylorus. 

OPERATIVE  FINDINGS:     Autopsy.     Extensive  carcinoma  of  the  oesophagus  with  secondary  involvement 
in  the  stomach. 

A     Pylorus. 

B  —  C     Extent  of  growth  in  pyloric  region  and  antrum. 


Figure  96 

PATIENT  — POSITION:     Man,  age  60.     Prone. 

ROENTGEN  CONCLUSIONS:     Carcinoma  at  pylorus  and  antrum  of  the  stomach. 

OPERATIVE  FINDINGS:     Resection  of  stomach.     Adenocarcinoma. 

A    Extent  of  process. 


Figure  97 


Artist's  drawing  of  Figure  96. 


Figure  98 

PATIENT  — POSITION:     Man,  age  48.     Prone. 

ROENTGEN  CONCLUSIONS:     Small  annular  carcinoma  at  antrum  of  the  stomach. 

OPERATIVE  FINDINGS:     Resection  of  stomach.     Adenocarcinoma. 

A     Extent  of  process. 


THE    ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


79 


FIGURE  95 


A 


FIGURE  97 


FIGURE   96 


FIGURE  98 


80  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  99 

PATIENT  — POSITION:     Man,  age  60.     Prone. 

ROENTGEN  CONCLUSIONS:     New  growth  in  antrum  of  stomach. 

OPERATIVE  FINDINGS:     Inoperable  carcinoma  of  stomach. 

A    Extent  of  process. 

Figure  100 

PATIENT  — POSITION:     Man,  age  53.     Prone. 

ROENTGEN  CONCLUSIONS :     Carcinoma  extending  practically  the  whole  length  of  the  lesser  and  greater 
curvature. 

OPERATIVE  FINDINGS:     Inoperable  carcinoma  of  the  stomach. 

A     Pylorus. 

B     Extent  of  process  on  lesser  curvature. 

C     Extent  of  process  on  greater  curvature. 

Note  intragastric  tumor  mass  which  displaces  the  bismuth. 

This  case  illustrates  the  obstructive  type  of  new  growth. 

Figure  101 

PATIENT  — POSITION:     Man,  age  60.     Prone. 

ROENTGEN  CONCLUSIONS:     Extensive  carcinoma  of  the  stomach  with  obstruction. 

OPERATIVE  FINDINGS:     Inoperable  carcinoma  of  the  stomach. 

A     Pylorus. 

B     Extent  of  process. 

This  case  illustrates  the  obstructive  type  of  new  growth. 

Figure   102 

PATIENT  — POSITION:     Man,  age  60.     Prone. 

ROENTGEN  CONCLUSIONS:     Probable  inoperable  carcinoma  of  the  stomach. 

OPERATIVE  FINDINGS:     Inoperable  carcinoma  of  the  stomach. 

A     Pylorus. 

B     Extent  of  process  on  greater  and  lesser  curvature. 

Obstruction  of  pylorus  causing  marked  dilatation  of  whole  stomach. 


THE  ROENTGEN  DIAGNOSIS  OF    SURGICAL  LESIONS 


81 


FIGURE  99 


FIGURE  100 


FIGURE  101 


FIGURE  102 


82  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  103 

PATIENT  — POSITION:     Woman,  age  56.     Prone. 

ROENTGEN  CONCLUSIONS:     Probable  inoperable  carcinoma  of  the  stomach. 

OPERATIVE  FINDINGS:     No  operation.    Subsequent  history  confirmed  Roentgen  diagnosis.     Death  three 
months  after  examination. 

A     Pylorus. 

B     Extent  of  growth  on  greater  and  lesser  curvature. 


Figure  104 

PATIENT  — POSITION:     Man,  age  63.     Prone. 

ROENTGEN  CONCLUSIONS:     Penetrating   gastric   ulcer   of  lesser   curvature.     Involvement   of  pylorus 
and  antrum  by  new  growth. 

OPERATIVE  FINDINGS:     Inoperable  carcinoma  of  the  entire  stomach. 

A  Result  of  the  old  ulcer  on  the  lesser  curvature  which  some  time  in  the  past  penetrated  or  formed  the 
sacculation.     The  obstruction  about  this  area  was  constant  throughout  the  examination. 

B  Pylorus.  Showing  small  intragastric  tumors  at  the  pylorus  and  involvement  at  the  gall-bladder  and 
lesser  curvature. 


Figure  105 

PATIENT  — POSITION:     Man,  age  63.     Prone. 

ROENTGEN  CONCLUSIONS:     Extensive  new  growth  in  antrum  of  the  stomach. 

OPERATIVE  FINDINGS:     laoperable  carcinoma  of  the  stomach. 

A     Extent  of  new  growth  in  stomach. 
B     Pylorus. 


Figure  106 

Artist's  drawing  of  Figure  105. 


THE  ROEXTGEX   DIAGNOSIS  OF  SURGICAL  LESIONS 


83 


FIGURE   103 


FIGURE    104 


Dfrdeiu 


5ca 


^oC^% 


FIGURE   105 


FIGURE   105 


84  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  107 

PATIENT  — POSITION:     Man,  age  54.     Prone. 
ROENTGEN  CONCLUSIONS:     Intragastric  tumor. 
OPERATIVE  FINDINGS:     Inoperable  carcinoma  of  the  stomach. 

A     Pylorus. 

B     Extent  of  process. 

It  is  interesting  to  note  in  this  case  the  intragastric  tumors  suggesting  a  polypoid  condition. 

At  operation  no  investigation  of  the  stomach  was  made  to  determine  the  character  of  this  growth. 

This  case  was  examined  six  months  later  and  found  not  only  to  have  gained  in  weight  45  pounds,  but 

the  Roentgen  plate  showed  the  process  more  extensive. 


Figure  107A 

PATIENT  —  POSITION:     Man,  age  58.     Prone. 

ROENTGEN  CONCLUSIONS:     Complete  involvement  of  the  whole  stomach  due  to  new  growth. 

OPERATIVE  FINDINGS:     Inoperable  carcinoma  of  the  entire  stomach. 

A     Pylorus. 

B     Extent  of  process,  extending  to  and  including  the  cardia. 


Figure  108 

PATIENT  — POSITION:     Man,   age  63.     Prone. 

ROENTGEN  CONCLUSIONS:     Intragastric  tumor,  pars  media. 

OPERATIVE  FINDINGS:     Inoperable  carcinoma  of  the  antrum  of  the  stomach. 

A — B     Extent  of  intragastric  tumors. 


Figure  109 

PATIENT  — POSITION:     Woman,  age  61.     Prone. 
ROENTGEN  CONCLUSIONS:     Gastric  new  growth. 
OPERATIVE  FINDINGS:     No  operation. 

A     Pylorus. 

B      Extent  of  growth. 

It  is  interesting  to   note  in  this  case  that  there  was  no  obstruction  at  the  pylorus.     In  fact  there  was 

marked  hypermotility.     Stomach  was  empty  in  one  hour. 


THE  ROEXTGEX   DIAGNOSIS   OF   SURGICAL  LESIOXt 


85 


FIGURE  107 


FIGURE    10:A 


FIGURE  108 


FIGURE  109 


86  THE   ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  110 

PATIENT  —  POSITION:     Man,   age  48.     Prone. 
ROENTGEN  CONCLUSIONS:     Hour-glass  stomach. 
OPERATIVE  FINDINGS:     Adenocarcinoma  of  stomach. 

A    Hour  glass. 
See  Figure  III. 

Figure   111 
The  same  case  as  Figure  110,  standing. 

This  shows  the  hour  glass  in  pars  media  due  to  intragastric  tumor. 
A     Extent  of  tumor. 

B     Narrowing  of  stomach  due  to  lumor  mass. 
The  operation  showed  a  large  intragastric  tumor. 
Adenocarcinoma. 


Figure  112 

PATIENT  — POSITION:     Man,  age  64.     Prone. 

ROENTGEN  CONCLUSIONS:     Large  new  growth  at  cardia  involving  the  upper  half  of  the  stomach. 

OPERATIVE  FINDINGS:     No  operation.     Death  within  three  months. 

A     Extent  of  tumor  mass  in  cardia. 


Figure  113 

PATIENT  — POSITION:     Man,   age  48.     Prone. 

ROENTGEN  CONCLUSIONS:     Postoperative  new   growth  involving  the  entire  stomach  antrum. 

OPERATIVE  FINDINGS:     Inoperable  carcinoma  of  the  antrum  of  the  stomach. 

This  case  was  operated  upon  eight  years  before  for  gastric  ulcer.     Good  recovery.     No  recurrence  of  gastric 

sj'mptoms  until  three  months  before  our  examination. 

It  is  to  be  noted  that  the  growth  has  progressed  even  to  the  ostium  within  that  short  period. 

A     Antrum. 

B     Ostimn. 

C     Duodenum. 

D     Lesser  curvature. 


THE  ROENTGEN   DIAGNOSIS  OF  SURGICAL   LESIONS 


87 


FIGURE    110 


FIGURE    112 


FIGURE   111 


FIGURE    113 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  114 

PATIENT  — POSITION:     Woman,  age  53.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  gastric  ulcer  of  pars  media  with  probable  beginning  degeneration. 

OPERATIVE  FINDINGS:     Inoperable    carcinoma   of   pars    media    and    cardia.     Extensive    inflammatory- 
tissue  about  this  area  suggesting  but  not  proving  the  Roentgen  diagnosis  of  chronic  ulcer. 

A  Roentgen  evidence  of  old  penetrating  ulcer. 

B  Involvement  of  the  stomach  by  new  growth. 

C  Extent  of  new  growth. 

D  Pylorus. 

Figure  115 

PATIENT  —  POSITION:     Man,  age  43.     Prone. 

ROENTGEN  CONCLUSIONS:     Inoperable  carcinoma  of  the  stomach  on  base  of  old  ulcer. 

OPERATIVE  FINDINGS:     Chronic  gastric  ulcer  and  inoperable  new  growth. 

A     Old  penetrating  ulcer. 
B     Extent  of  growth. 

Figure  116 

PATIENT  — POSITION:     Man,  age  53.     Prone. 

ROENTGEN  CONCLUSIONS:     Intragastric  tumor  of  the  greater  curvature.     Not  positive  but  suggestive 
Roentgen  evidence. 

OPERATIVE  FINDINGS:     Extensive  involvement  of  the  greater  curvature  of  the  stomach  by  intragastric 
tumors. 

A     Beginning  of  filling  defect  in  stomach. 
B     Extension  along  greater  curvature. 


Figure  117 

PATIENT  — POSITION:     Man,  age  63.     Prone. 

ROENTGEN  CONCLUSIONS:     Inoperable  carcinoma  at  cardia. 

OPERATIVE  FINDINGS:     Autopsy. 

A     Involvement  of  cardia. 


THE  ROEXTGEN  DIAGNOSIS   OF   SURGICAL   LESIOXS 


89 


FIGURE   114 


FIGURE  115 


FIGURE   116 


FIGURE  117 


90  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


Figure  118 

PATIENT  —  POSITION:     Man,  age  52.     Prone. 

ROENTGEN  CONCLUSIONS:     Small  intragastric  tumor  in  cardia. 

OPERATIVE  FINDINGS:     Small  intragastric  tumor  in  cardia. 

A — B     Outline  of  tumor  mass  without  bismuth. 
C    Diaphragm. 
D     Cardia. 

At  first  the  lesion  was  not  detected  in  presence  of  the  bismuth  meal  but  further  inspection  of  the  Roentgen- 
ograms of  bismuth  series  revealed  a  small  tumor  mass. 


Figure  119 

PATIENT— POSITION:     Man,  age  58.     Prone. 

ROENTGEN  CONCLUSIONS:     Extensive  new  growth  at  cardia. 

OPERATIVE  FINDINGS:     Autopsy. 

A — B — C     Extent  of  involvement  about  cardia. 


Figure  120 

PATIENT  —  POSITION:     Man,  age  58.     Prone. 

ROENTGEN  CONCLUSIONS:     Extensive  new  growth  of  entire  stomach. 

OPERATIVE  FINDINGS:     Inoperable  new  growth  of  stomach. 


Figure  121 

PATIENT— POSITION:     Man,  age  56.     Prone. 

ROENTGEN  CONCLUSIONS:     Inoperable  new  growth  of  pars  media  of  the  stomach. 

OPERATIVE  FINDINGS:     Extensive  new  growth  of  stomach. 

A     Beginning  of  the  process. 


THE    ROEXTGEX   DIAGNOSIS   OF   SURGICAL   LESIONS 


91 


FIGURE   118 


FIGURE  119 


FIGURE   120 


FIGURE    121 


92  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


SECTION  IV 

ULCER  OF  THE  DUODENUM 

Definition  —  Pathology  —  Possibility  of  a  Positive  Diagnosis — "Seven 

Propositions"  —  Serial  Plates  —  Presumptive  Evidence  — 

Value  of  Roentgenoscope 

Since  the  brilliant  work  of  Moynihan,  Patterson  and  William  Mayo  was  accepted  by 
the  medical  profession,  no  new  evidence  in  the  diagnosis  of  duodenal  ulcer  that  was  positive 
in  character  was  presented  until  Cole  of  New  York  proved  the  possibility  of  the  direct 
diagnosis  of  pathological  lesions  in  the  first  portion  of  the  duodenum  by  serial  Roent- 
genography. The  writers  have  agreed  with  Cole  in  all  his  contentions,  but  have  modified 
somewhat  his  technique  in  the  study  of  the  duodenum.  The  diagnosis  of  duodenal  ulcer 
by  the  Roentgen  ray,  especially  by  the  direct  method,  is  one  of  simpUcity.  It  offers  no 
particular  difficulties  other  than  that  of  care  in  technique.  For  convenience  and  clearness, 
the  whole  question  depends  upon  the  following  propositions,  which  are  substantially  based 
upon  the  work  of  Cole  and  his  observations,  which  have  stood  the  test  better  than  all  other 
methods  up  to  date. 

First.  The  direct  method  consists  in  demonstrating  adequately  the  anatomical  con- 
dition of  the  first  portion  of  the  duodenum.  This  is  opposed  to  the  conception  of  the 
symptom-complex,  which  emphasizes  only  inferential  evidence  and  is  not  conclusive  as 
compared  with  the  direct  method  where  we  actually  try  to  demonstrate  the  lesion. 

Second.  Ninety-five  per  cent  of  all  duodenal  ulcers  occur  in  the  first  portion  of  the 
duodenum. 

Third.     Anatomically,  the  first  portion  of  the  duodenum  is  a  constant  entity. 

Fourth.  If  normal,  the  first  portion  of  the  duodenum  can  always  be  demonstrated  on 
a  plate  with  characteristic  shape  and  smooth  outline.  There  is  no  exception  to  this  rule. 
Apparent  exceptions  are  due  to  improper  technique. 

Fifth.  A  constant  defect  in  this  duodenal  cap  on  the  plate  means  a  pathological  con- 
dition. This  may  be  ulcer,  adhesions  due  to  cholecystitis,  or  anatomical  or  accidental  varia- 
tions such  as  pressure  from  adjacent  organs. 

Sixth.  Any  duodenal  ulcer  which  is  more  than  a  simple  mucous  membrane  erosion 
will  deform  the  outhne  of  the  bismuth  mass.    To  this  statement  there  is  no  exception. 

Seventh.  A  normal  "bulbus  duodeni,"  or  duodenal  cap  on  the  plate,  rules  out  chronic 
indurated  or  surgical  ulcer.  There  is  one  exception  to  this  rule:  that  is  the  minute  recent 
ulcer  which  perforates  without  prodromal  symptoms.  However,  we  are  not  obhged  to 
consider  this  from  a  Roentgen  point  of  view. 

In  the  direct  method  of  examination  of  duodenal  ulcer,  no  little  effort  must  be  made 
to  show  the  anatomical  condition  of  the  first  portion  of  the  duodenum  on  the  plate.  In  the 
average  case  it  is  simple,  but  occasionally  the  problem  of  pjdoric  spasm,  pressure  from 
adjacent  organs  such  as  a  large  and  distended  gall-bladder,  enlarged  lobes  of  the  liver,  spasm 
due  to  cholecystitis,  gall-stones,  pelvic  conditions,  chronic  appendicitis,  and  obstructive 
conditions  of  the  large  and  smaU   bowel   may  make  it  more  difficult.    The  size  of  the  indi- 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS  93 

vidual,  the  amount  of  mesenteric  fat  and  general  condition  of  the  abdominal  cavity,  all 
play  an  important  part  in  the  ease  with  which  the  duodenmn  can  be  demonstrated  on  the 
Roentgen  plate.  No  set  rule  can  be  made  as  to  how  this  can  be  accomplished.  Plates 
should  be  made  with  the  patient  in  the  prone  position  at  first,  and  in  the  majority  of  cases 
the  first  portion  of  the  duodenum  will  completely  fill  with  no  angulation  of  the  smooth 
edges  of  the  superior  and  inferior  borders,  as  well  as  the  pjdoric  sphincter. 

Time  must  be  given  for  the  stomach  to  start  emptjdng.  This  may  vary  from  the  mo- 
ment of  taking  the  first  mouthful  to  the  first  hour.  In  the  average  case,  as  soon  as  the 
patient  has  had  the  meal  and  is  in  position  on  the  table,  the  first  portion  of  the  duodenum 
should  be  visualized.  If  one  is  sure  there  is  no  other  lesion  but  the  possibility  of  duodenal 
ulcer,  we  have  found  that  half  the  usual  meal  wiU  show  the  deformity  better  than  the 
complete  meal.  If  the  duodemun  does  not  fill  out  completeh"  and  one  finds  a  picture  of 
apparent  deformit}^,  by  placing  the  patient  right  side  down  on  the  table  with  the  plate 
underneath,  using  a  small  cjdinder,  localizing  for  the  average  stomach  midway  on  the  costal 
cartilage,  the  plate  will  show  the  first  portion,  the  beginning  of  the  descending  and  part 
of  the  transverse  duodenum  in  practically  the  same  relations  as  one  sees  these  parts  on  the 
plates  when  taken  in  the  prone  position.  In  the  difficult  cases  it  may  mean  ten  to  fifteen 
minutes  with  the  patient  on  the  side  before  the  duodenum  will  fill  completely.  These  are 
the  cases  in  which  the  patient  is  large  or  spasm  is  present.  As  a  rule,  plates  should  be  made 
at  intervals  for  an  hour  before  passing  an  opinion  of  duodenal  ulcer  on  the  deformity  alone. 
In  showing  a  normal  first  portion,  effort  should  be  made  to  carry  out  the  technique  over 
a  period  of  at  least  an  hour.  One  of  the  plates  shoidd  show  the  duodenum  completely 
fiUed  if  it  is  normal.  To  this  there  is  hardly  an  exception  unless  a  large  liver,  new  growth 
of  the  gall-bladder,  or  some  other  factor  causes  deformity  by  compression. 

Occasionally  the  only  way  the  first  portion  of  the  duodenum  can  be  shown  is  in  the 
upright  position.  With  all  mixtures  except  the  buttermilk  mixture,  it  is  difficult  to  fill  the 
duodenum  completely  in  the  upright  position.  This  has  been  one  of  the  great  sources  of 
error  in  the  inferential  studj'  by  the  Roentgenoscope.  One  should  not  change  from  the 
prone  to  the  lateral  and  to  the  upright  position  without  an  effort  being  made  for  a  reason- 
able length  of  time  to  get  the  cap  in  some  one  position.  But  it  is  only  in  the  exceptional 
case  that  the  first  portion  of  the  duodemmi  is  slow  to  fill. 

That  the  first  portion  of  the  duodemmi  is  a  constant  entity  is  the  criterion  of  the 
truth  of  the  direct  method.  From  a  large  series  of  examinations  of  the  duodemmi  by  the 
serial  method,  we  are  not  alone  in  being  convinced  that  the  first  portion  of  the  duodenum  is 
constant  unless  there  is  some  pathology  of  the  duodenum  itself  or  of  neighboring  structures, 
as  of  the  pylorus,  and,  whether  the  duodenum  is  large  or  small  or  average  size,  its  borders 
Roentgenographically  will  always  be  smooth  when  normal. 

If  it  be  admitted  that  with  a  series  of  plates,  or  Cole's  serial  method,  a  normal  duo- 
denal cap  can  be  shown  when  it  is  normal,  then  the  converse  of  the  proposition  must  be 
true. 

It  is  quite  remarkable  that  practically^  all  the  investigators  on  the  Continent  did  not 
seem  able  to  reproduce  the  first  portion  of  the  duodenum  on  the  photographic  plate,  or  at 
least  they  laid  a  great  deal  of  stress  on  the  fact  that  it  is  difficult  to  do.  We  believe  it  to 
be  solely  a  matter  of  improper  technique,  in  part  due  to  the  kind  of  meal  used. 

It  would  seem,  then,  that  only  one  important  question  remains;  that  is,  mil  all  ulcers 
of  the  duodenum  show  on  the  Roentgen  plate? 

Dr.  Wilhani  Maj'o  published  a  pathological  study  of  a  nmnber  of  cases  of  ulcers  ex- 
cised from  the  anterior  waU  of  the  first  portion  of  the  duodenum  (Annals  of  Surgery,  1913, 
Ivii,  p.  691)  that  seemed  to  have  a  different  character  from  the  classical  gastric  ulcers,  which 


94  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 

show  a  relatively  broad,  punched-out,  callous  defect  in  the  mucosa  with  extensive  indura- 
tion. These  duodenal  ulcers,  however,  often  showed  merely  a  pinpoint  defect  on  the  mu- 
cosal surface  with  some  mucous  membrane  heaped  about  them.  Though  we  do  not  make 
.  bold  to  claim  that  a  pinpoint  mucosal  defect  will  always  show  on  the  Roentgen  plate,  we 
do  not  feel  it  to  be  overstating  the  case  to  say,  that  if  proper  technique  is  used  in  a  majority 
of  the  cases  such  a  mucosal  defect  will  show.  It  should  be  remembered  that  in  this  type  of  ulcer 
the  amount  of  callus  in  the  submucosal,  muscular  and  peritoneal  coats  bears  absolutely 
no  relation  to  the  minute  size  of  the  ulcer  itself,  which  probably  accounts  for  the  Roent- 
genographic  appearance  of  these  ulcers,  which  seems  exaggerated  when  compared  with  the 
operative  findings.  In  no  other  part  of  the  gastro-intestinal  tract  is  the  deforming  effect 
produced  by  connective  tissue  upon  the  bismuth  mass  so  apparent  as  in  the  first  portion 
of  the  duodenum. 

The  Roentgenologist  knows  that  the  amount  of  deformity  shown  on  the  plate  taken 
when  the  bismuth  is  passing  through  the  duodenum  may  seem  to  belie  the  appearance 
of  the  duodenum  as  presented  at  operation.  A  certain  percentage  of  cases  show  on  the 
Roentgen  plate,  opposite  the  ulcer,  an  incisura  partly  spastic  in  character,  but  mostly  due 
to  the  involvement  of  the  deep  muscle  layers  by  connective  tissue  or  cicatrix.  If  a  plate 
could  be  obtained  in  every  case  while  the  descending  portion  of  the  duodenum  were  held 
to  one  side  so  that  it  would  not  underlie  the  view  obtained  of  the  first  portion  of  the  duo- 
denum, then  the  incisura  would  be  more  apparent  than  it  is  in  the  majority  of  cases. 

The  problem  of  whether  an  ulcer  can  exist  as  a  simple  erosion  is,  we  believe,  academic. 
Such  an  ulcer  would  be  unlikely  to  give  any  symptoms  and  hence  is  of  no  immediate  interest 
to  the  clinician  or  to  the  Roentgenologist. 

The  pitfall  for  the  novice  in  the  Roentgen  study  of  the  duodenum  is  the  differentiation 
of  the  deformity  due  to  ulcer  to  that  due  to  adhesions.  Differentiation  can  be  made  readily 
between  simple  adhesions  and  ulcer  of  the  duodenum.  But  where  one  finds  a  combination 
of  ulcer  of  the  duodenum  and  adhesions,  one  cannot  say  always,  nor  is  it  necessary,  whether 
these  adhesions  are  due  to  the  ulcer,  or  to  gall-bladder  disease,  or  to  both.  It  is  sufficient  to 
pass  the  opinion,  which  we  can  do  from  the  Roentgen  plate,  that  there  is  a  surgical  lesion. 

In  simple  adhesions,  no  matter  how  extensive,  the  deformity  of  the  bismuth  mass  is 
greater  at  the  beginning  of  the  examination,  gradually  lessening  as  the  stomach  empties, 
and  while  the  stomach  when  first  filled  will  be  found  in  the  subhepatic  region,  it  will  be 
found  in  successive  plates  to  move  back  to  the  median  line  as  it  empties. 

When  the  degree  of  deformity  remains  the  same  from  the  beginning  of  the  examination 
until  the  stomach  has  almost  emptied  itself,  it  is  more  characteristic  of  ulcer.  A  constant 
deformity  of  the  duodenum  is  peculiar  to  ulcer  and  to  no  other  lesion. 

That  a  normal  first  portion  of  the  duodenum  rules  out  indurated  or  surgical  ulcer  in- 
creases many  times  the  negative  value  of  a  Roentgen  diagnosis  by  serial  plates.  Whenever 
we  demonstrate  the  first  portion  of  the  duodenum  to  be  free  from  deformity,  we  pass  a 
negative  opinion.  Once  only,  out  of  a  series  of  over  a  hundred  cases  which  came  to  opera- 
tion, was  our  opinion  unconfirmed. 

Much  of  the  usefulness  of  the  Roentgen  method  lies  in  this  negative  aspect.  Negative 
evidence,  however,  is  of  greater  value  as  referred  to  the  duodemmi  than  to  the  stomach. 

We  find,  then,  that  the  Roentgen  diagnosis  of  duodenal  ulcer  by  the  direct  method 
basically  rests  upon  the  demonstration  by  serial  Roentgen  plates  of  the  continuity  of  the 
first  portion  of  the  duodenum,  or  the  demonstration  of  a  constant  defect  in  its  contour. 
There  is  no  better  argument  for  the  plate  method  than  that  this  can  be  accomplished  un- 
failingly. The  indirect  method,  as  emploj^ed  by  Dr.  R.  E.  Carman  of  the  Maj^o  Clinic, 
demands   careful    review  because  the  large    number    of    cases    examined    by  that    method 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS  95 

under  his  direction  give  credence  to  the  accuracy  of  the  data  drawn  therefrom.  He  has 
divided  the  Roentgen  signs  of  duodenal  ulcer  into  major  and  minor  groups.  The  major 
signs  consist  of  "hyperperistalsis,  six-hour  gastric  residue  and  demonstrable  diverticulum 
of  the  duodenum." 

Gastric  hyperperistalsis  has  been  emphasized  more  than  any  other  sign.  The  writers 
have  stated,  "abnormally  marked  peristalsis  is  an  important  sign  if  found."  The  difficulty 
is  that  even  with  Carman's  large  series  it  was  present  in  only  fifty-seven  per  cent  of  the 
proved  cases  of  duodenal  ulcer.  It  was  found  in  pyloric  stenosis  due  to  other  causes  than 
ulcer,  as  early  carcinoma  and  abnormal  nervous  conditions.  We  have  seen  violent  hyper- 
peristalsis in  individuals  with  no  organic  disease  present.  Its  presence  is  hardly  more  than 
suggestive  and  its  absence  certainly  does  not  warrant  a  negative  diagnosis.  We  believe  it 
a  very  treacherous  basis  upon  which  to  found  a  diagnosis  of  duodenal  ulcer. 

Six-hour  bismuth  residue  in  the  stomach  depends  to  a  large  degree,  as  has  been  already 
stated,  upon  the  character  of  the  bismuth  meal  used.  The  large  number  of  Roentgen  ex- 
aminations made  by  Carman  justifies  him,  no  doubt,  in  attaching  a  definite  significance  to 
the  presence  of  a  six-hour  stasis  with  his  particular  meal  and  technique.  He  found  this 
residue,  however,  in  only  33.3  per  cent  of  his  cases  of  duodenal  ulcer.  This  corresponds 
fairly  well  with  the  observations  of  other  investigators.  Indeed,  Holzknecht  and  Haudek 
found  this  residue  in  onlj'  twenty  per  cent  of  their  duodenal  ulcers.  Thus  it  would  seem 
that  at  the  very  best,  about  two  thirds  of  duodenal  ulcers  give  no  positive  information 
as  to  this  major  diagnostic  sign. 

A  diverticulum  of  the  duodenum,  so-called,  is  undoubtedly  important  when  present. 
Carman  found  it  in  only  two  cases  out  of  one  hundred  and  ninetj^-eight.  The  writers  have 
seen  this  condition  in  about  six  cases.  Its  raritj^  militates  against  its  effectiveness  as  a  con- 
stant factor  in  diagnosis. 

IncidentaU}',  we  do  not  believe  that  this  diverticulum  is  due  at  all  to  a  penetrating 
duodenal  ulcer  in  the  sense  that  "Haudek's  niche"  is  produced  by  a  penetrating  gastric 
ulcer.  Such  a  penetration  is  extremely  rare  in  duodenal  ulcer  and  onlj^  two  cases  have 
been  noted.  In  our  experience  these  diverticula  have  been  caused  by  a  pull  of  adhesions 
for  a  considerable  length  of  time  which  finally  resulted  in  the  production  of  small  saccula- 
tions. Sometimes,  also,  such  sacculations  may  be  the  result  of  a  cicatrizing  process  which 
involves  all  the  duodenal  cap  except  one  small  section  in  which  the  wall  is  normal  and  which 
contains  a  bismuth  residue. 

We  are  forced  to  the  conclusion,  in  respect  to  these  so-called  "major  signs,"  that  the 
one  sign  which  is  considered  most  valuable,  gastric  hyperperistalsis,  leaves  us  without  help 
in  at  least  forty-three  per  cent  of  cases.  The  combination  of  hyperperistalsis  and  six-hour 
gastric  residue  was  found  in  only  24.7  per  cent  of  his  cases,  yet  Carman  states  they  are 
"worth  more  than  ninety-five  per  cent  in  the  diagnosis  of  duodenal  ulcer."  This,  on  the 
face  of  it,  seems  hardly  compatible  with  his  statistics. 

Again  he  states  that  "the  combination  of  hyperperistalsis  and  six-hour  residue  or 
diverticulum,  when  found  in  an  otherwise  normal  stomach,  constitutes  about  the  only  evi- 
dence on  which  a  purely  radiologic  diagnosis  of  duodenal  ulcer  may  safelj^  be  advanced." 
If  this  is  true,  then  in  at  least  seventy-five  per  cent  of  cases  a  purely  Roentgen  diagnosis 
is  impossible.    The  results  of  the  direct  method  certainlj-  do  not  support  this  statement. 

As  a  matter  of  practice,  the  writers  know  these  so-caUed  major  signs  are  not  depend- 
able and,  as  a  matter  of  deduction.  Carman's  own  statistics  are  open  only  to  the  same 
conclusion. 


96  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 

Let  us  examine  what  he  calls  "minor  signs"  in  Roentgen  diagnosis  and  accord  at  once 
with  him  as  to  their  relatively  inferior  value  in  all  but  one  instance,  which  we  shall  consider 
last. 

Hypermotility  of  the  stomach  is  a  sign  which  we  agree  is  by  no  means  pathognomonic 
of  ulcer,  since  it  occurs  in  achylia  gastrica,  carcinoma,  and  motor  neuroses.  In  duodenal 
ulcer  the  presence  of  hypermotility  results  from  a  physiological  tendency  towards  rapid 
emptying  of  the  stomach  due  to  duodenal  irritation  on  one  hand  and  the  mechanical  ob- 
struction from  the  cicatrized  portion  of  the  duodenum  on  the  other.  The  results  are  so 
variable  that  they  offer  no  basis  for  definite  conclusions  to  be  appUed  to  any  particular 
case. 

Hypertonus  of  the  stomach,  the  presence  of  pressure  tender-points  and  the  lagging  of 
bismuth  in  the  duodenum  we  are  agreed  are  minor  signs  in  the  Roentgen  diagnosis  of  duo- 
denal ulcer  and  no  one  of  them  is  pathognomonic.  Reliance  on  these  signs  is  certain  to 
lead  to  errors  of  diagnosis. 

When,  however,  we  consider  the  last  of  Carman's  minor  signs;  namely,  deformity  of 
the  outline  of  the  duodenal  cap,  we  must  emphatically  protest  against  including  this  among 
the  minor  signs.  The  word  "irregularity"  does  not  convey  sufficiently  the  idea  as  to  just 
what  we  are  attempting  to  demonstrate  by  the  direct  study  of  these  cases.  What  we  try  to 
show  in  every  instance  is  either  a  normal  duodenum  or  the  exact  size,  extent  and  character 
of  the  lesion.    The  entire  problem  revolves  about  the  method  of  study  of  the  duodenum. 

In  the  application  of  the  Roentgen  ray  to  surgery  generally,  the  development  has  always 
been  along  the  lines  of  attempting  to  obtain  positive  data  and  eliminating  all  bases  for 
diagnosis  that  are  uncertain  and  indefinite.  This  trend  is  seen  already  in  the  Roentgen 
study  of  fractures,  bone  disease,  and  renal  calculi.  The  same  point  of  view  is  equally  true 
when  applied  to  duodenal  ulcer.  The  only  basis  for  a  definite  opinion  should  be  the  actual 
demonstration  of  a  normal  or  abnormal  duodenum.  The  direct  school  of  diagnosis  disre- 
gards all  the  indirect,  so-called  "major"  or  "minor"  signs,  and  restricts  itself  to  one  prob- 
lem; namely,  the  attempt  to  demonstrate  adequately  the  anatomical  condition  of  the  duo- 
denum and  the  determination  as  to  whether  the  duodenum  so  demonstrated  is  normal  or 
pathological.    This  problem  is  largely  one  of  careful  and  exact  technique. 

The  Roentgenoscopic  method,  when  applied  to  the  study  of  the  duodenal  ulcer  from 
this  point  of  view,  is  entirely  unsatisfactory.  It  is  true  that  sometimes  the  duodenum  can 
be  seen  in  its  entirety,  but  it  can  never  be  seen  for  a  long  enough  time  to  satisfy  one  as  to 
its  anatomical  completeness.  It  certainly  cannot  be  shown  in  all  cases,  especially  in  well- 
nourished  individuals.  In  the  standing  position  in  which  the  Roentgenoscope  is  ordinarily 
used,  this  demonstration  is  usually  impossible.  All  that  can  be  shown  is  the  pressure  of  the 
bismuth  into  the  cap,  which  is  speedily  emptied. 

It  is  only  with  the  plate  method,  carefully  carried  out,  that  the  duodenum  can  be 
demonstrated  in  its  entirety.  We  do  not  mean  to  infer  that  the  Roentgenoscopic  study  of 
the  gastro-intestinal  tract  is  worthless.  The  Roentgenoscope  has  undoubtedly  its  valuable 
appfications  in  the  study  of  the  stomach  and  many  other  parts  of  the  alimentary  tract. 
However,  when  it  comes  to  the  study  of  the  duodenum  and  the  problems  involved  in  duo- 
denal ulcer,  the  Roentgenoscope  must  really  be  considered  as  of  minor  value. 

Serial  Roentgen  plates  are  the  ideal  method  of  studying  these  cases  and  it  is  not 
necessary  always  to  take  an  extremely  large  number  of  plates.  Only  enough  plates  need 
be  taken  as  will  convince  the  investigator  of  either  the  normal  condition  of  the  duodenum 
or  its  constant  abnormal  condition.    No  set  rules  can  be  given  as  to  the  position  of  the 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS  97 

patient  during  the  examination.  All  the  positions,  prone,  standing  and  lateral,  may  have 
to  be  used  in  order  to  obtain  the  desired  information.  The  exact  procedure  to  be  followed 
must  be  worked  out  in  each  individual  case  as  the  problems  present  themselves.  This 
requires  the  use  of  rapid  developers  and  the  development  of  plates  during  the  progress  of 
the  examination.  Of  course,  this  is  a  more  troublesome  process  than  the  indirect  method, 
but  the  more  accurate  results  obtained  are  certainly  worth  the  bit  of  extra  labor  and 
expense. 

Note.  Since  going  to  press  Dr.  R.  C.  Carman  in  a  paper  read  at  the  annual  meeting  of  the  American  Roentgen  Ray 
Society,  September,  191.5,  at  Atlantic  Citj',  stated  that  he  now  considers  deformity  of  the  duodenal  cap  a  major  sign  in  the  diag- 
nosis of  duodenal  ulcer  and  that  since  accepting  this  he  has  made  more  diagnoses  of  duodenal  ulcer  which  have  been  confirmed 
at  operation. 


98  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


DUODENUM 


Figure  122 

PATIENT  — POSITION:     Woman,  age  25.     Prone. 

ROENTGEN  CONCLUSIONS:     Normal. 

OPERATIVE  FINDINGS:     Exploratory.     Stomach  and  duodenum  found  normal. 

Key  plate. 

1  Region  of  the  cardia. 

2  Pars  media. 

3  Pars  pylorica  or  antrum. 

4  Pylorus. 

5  First  portion  of  the  duodenum. 

6  Second  portion  of  the  duodenum. 

7  Third  portion  of  the  duodeniun. 

This  plate  is  used  as  an  average  normal  Roentgenogram  of  a  normal  individual.  It  shows  the  superior 
and  inferior  borders  of  the  duodenum  perfectly  smooth  and  regular.  The  pyloric  region  of  the  duodenum 
is  regular  in  outline. 


Figure  123 

Artist's  dra"ning. 

Extensive  surface  of  ulcer  on  the  anterior  wall  of  the  duodenum. 


Figure  124 

Artist's'  dra-R-ing. 

Mucosal  surface  of  ulcer  on  anterior  wall  of  the  duodenum.     (Permission  of  Dr.  William  Mayo.) 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


99 


FIGURE   122 


FIGURE   123 


FIGURE   124 


100  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  125 

PATIENT  — POSITION:     Man,  age  38.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     Chronic  ulcer  of  the  anterior  wall  of  the  duodenum. 

A     Mucosal  defect  of  the  superior  border  of  the  duodenum. 
B     Deforming  effect  of  scar  tissue. 


Figure  126 

PATIENT  —  POSITION:     Man,  age  42.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     Chronic  ulcer  of  the  duodenum. 

A    Effect  of  coimective  tissue  about  the  ulcer. 

B     Mucosal  defect. 

C    Incisura  partly  due  to  spasm  but  mostlj'  to  the  deforming  effect  of  tissue. 


Figure  127 

PATIENT  —  POSITION:     Woman,  age  38.     Prone. 
ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     Chronic  ulcer   of  the   duodenum   with  extensive   involvement   of  the   duode- 
num due  to  chronic  ulcer  of  the  anterior  wall. 

A    Large  mucosal  defect. 

B    Effect  of  connective  tissue  deforming  the  outline  of  the  duodenum. 


Figure  128 

PATIENT  — POSITION:     Man,  age  3L     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     Chronic  ulcer  of  the  duodenum  with  extensive  scar  formation. 

A    Mucosal  defect. 

B    Deforming  effect  of  scar  tissue. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


101 


FIGURE  125 


FIGURE  126 


FIGURE   127 


FIGURE  128 


102  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


Figure  129 

PATIENT  — POSITION:      Woman,  age  48.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     Extensive  involvement  of  the  duodenum  by  scar  from  old  ulcer  and  adhesions. 

A     Pjdorus. 

B     Almost  complete  obliteration  of  the  duodenum. 


Figures  130  and   130A 

PATIENT  — POSITION:     Woman,  age  40.     Lateral. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     A  small  chronic  ulcer  of  the  superior  wall  of  the  duodenum. 

A    The  deforming  effect  of  connective  tissue. 

B     Mucosal  defect. 

This  case  could  not  be  diagnosed  in  either  the  upright  or  prone  positions  as  there  was  no  apparent  deformity. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


103 


FIGURE    129 


FIGURE   130A 


104  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figures  131  and  131 A 

PATIENT  — POSITION:     Man,  age  48.     Lateral. 

ROENTGEN  CONCLUSIONS:     Ulcer  of  the  superior  and  inferior  borders  of  the  duodenum. 

OPERATIVE  FINDINGS:     Extensive  involvement  of  the  duodenum  due  to  an  ulcer  both  of  the  superior 
and  inferior  borders  of  the  duodenum. 

A    Mucosal  defect  of  the  superior  border  of  the  duodenum. 
B     Mucosal  defect  on  the  inferior  border  of  the  duodenum. 


Figure  132 

PATIENT  — POSITION:     Man,  age  40.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     Chronic  ulcer  of  the  duodenum. 


A     Large  mucosal  defect. 

B     Deforming  effect  of  connective  tissue. 


Figure  133 

Same  case  as  Figure  132.     Plate  made  fifteen  minutes  after  Figure  132. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


105 


FIGURE  131 


FIGURE  131A 


FIGURE  132 


FIGURE   133 


106  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL  LESIONS 


Figure  134 

PATIENT  — POSITION:     Man,  age  55.     Prone. 

ROENTGEN  CONCLUSIONS:     Duodenal  ulcer;  probably  beginning  carcinoma  at  the  pylorus  and  antrum 

of  the  stomach. 
OPERATIVE  FINDINGS:     Annular  carcinoma  of  the  antrum  of  the  stomach. 

A     Scar  of  old  ulcer  of  the  duodenum. 


Figure  135 

PATIENT  —  POSITION:     Woman,  age  48.     Standing. 

ROENTGEN  CONCLUSIONS:     Ulcer  of  the  duodenum,  also  ulcer  of  the  lesser  curvature  of  the  stomach, 

posterior  wall. 
OPERATIVE  FINDINGS:     Chronic  ulcer  of  the  duodenum,  also  a  large  florid  ulcer  of  the  lesser  curvature 

of  the  stomach,  posterior  wall. 

A     Deforming  effect  of  ulcer  in  duodenum. 

B     Deforming  effect  of  ulcer  of  posterior  wall  of  the  stomach. 


Figure  136 

PATIENT  — POSITION:     Woman,  age  39.     Prone. 

ROENTGEN  CONCLUSIONS:     Probable  ulcer  of  the  duodenum  with  adhesions. 

OPERATIVE  FINDINGS:     Operation  six  months  after  examination  revealed  involvement  of  the  duodenum 
due  to  old  ulcer.     No  adhesions. 

A     Duodenum  showing  deforming  effect  due  to  ulcer. 

The  characteristic  ulcer  deformity  was  not  visualized  in  the  prone  position. 


Figure  137 

Same  case  as  Figure  136,  lateral  view. 

A — B     Deforming  effect  of  ulcer  in  the  duodenum. 

Note  the  more  characteristic  appearance  of  ulcer  in  this  position. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


107 


FIGURE    134 


108  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  138 

PATIENT  —  POSITION:     Man,  age  33.     Prone. 

ROENTGEN  CONCLUSIONS:     Complete  obliteration  of  the  duodenum  due  to  ulcer. 

OPERATIVE  FINDINGS:     Chronic  ulcer  of  the  duodenum. 

A    Obliteration  of  duodenum  due  to  coimective  tissue. 


Figure  139 

PATIENT  —  POSITION:     Man,  age  43.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum  with  probable  adhesions. 
OPERATIVE  FINDINGS:     Extensive  involvement  of  the  duodenum  by  adhesions  from  the  gall-bladder 
and  liver. 

A^B    The  serrated  effect  about  the  duodenum  is  suggestive  of  adhesions  and  not  of  ulcer. 


Figure  140 

PATIENT  —  POSITION:     Man,  age  32.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:  Obliteration  of  duodenum  due  to  chronic  ulcer  and  adhesions. 

A     Small  amount  of  bismuth  filling  duodenum. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


109 


FIGURE   138 


FIGURE  139 


FIGURE  140 


110  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  141 

PATIENT  — POSITION:     Man,  age  62.     Prone. 

ROENTGEN  CONCLUSIONS:  Chronic  ulcer  of  the  duodenum  with  probable  adhesions.     Gall-stones. 

OPERATIVE  FINDINGS:     Perforation  of  gall-bladder  into  duodenum  with  extensive  adhesions  and  narrow- 
ing of  duodenum.     Sixty-seven  gall-stones. 

A    Outline  of  one  gall-stone. 

B     This  was  supposed  to  be  a  mucosal  defect  but  proved  to  be  a  perforation  into  the  gall-bladder  of  the 

duodenum. 
C    Effect  of  pressure  from  the  gall-bladder  on  the  duodenum. 


Figure  142 

Lateral  view  of  same  case  (Figure  141). 
A     Pylorus. 

B     This  was  supposed  to  be  a  mucosal  defect;  at  operation  proved  to  be  perforation  of  the  gall-bladder 
into  the  duodenum. 


Figure  143 

PATIENT  — POSITION:     Man,  age  40.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum  with  possible  beginning  perforation. 

OPERATIVE  FINDINGS:  Beginning  perforation  of  ulcer  of  the  superior  border  of  the  duodenum. 

A     Pylorus. 
B     Perforation. 

Figure  144 

PATIENT  — POSITION:     Woman,  age  32.     Prone. 

ROENTGEN  CONCLUSIONS:     Very  small  ulcer  on  the  superior  border  of  the  duodenum. 

OPERATIVE  FINDINGS:     Very  small  ulcer  of  the  anterior  wall  of  the  duodenum. 

A     A  fine  pinpoint  mucosal  defect. 

B     Defect  partly  due  to  spasm  and  partly  due  to  the  involvement  of  the  duodenum  by  connecting  tissue. 


THE   ROENTGEN   DIAGNOSIS  OF  SURGICAL  LESIONS 


111 


FIGURE    141 


FIGURE   142 


FIGURE   143 


FIGURE   144 


112  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  145 

PATIENT  — POSITION:     Man,  age  50.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum,  the  obstructive  type. 

OPERATIVE  FINDINGS:     Complete   obliteration    of  the   first   portion    of   the   duodenum  with  marked 
adhesions.     The  stomach  was  greatly  dilated  and  contained  bismuth  residue  after  thirty-six  hours. 

A    Ulcer  of  the  duodenum. 

B     Pylorus. 

C     Fixation  of  the  duodenum  in  the  subhepatic  region. 


Figure  146 

PATIENT  — POSITION:     Man,  age  53.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum,  obstructive  type. 

OPERATIVE  FINDINGS:     Extensive  ulcer  of  the  duodenum  involving  the  pyloric  sphincter. 

A     Effect  of  ulcer  upon  the  first  portion  of  the  duodenum. 

B     Pylorus. 

This  case  showed  a  marked  twenty-four  hour  gastric  stasis,  probably  due  to  the  involvement  of  the  pyloric 

sphincter  by  connective  tissue  arising  from  the  ulcer  in  the  duodenum. 


Figure  147 

PATIENT  — POSITION:     Man,  age  28.     Prone. 

ROENTGEN  CONCLUSIONS:     Small  ulcer  on  the  superior  border  of  the  duodenum. 

OPERATIVE  FINDINGS:     Small  ulcer  and  a  large  adhesion  arising  from  anterior  wall  of  the  duodenum. 

A     Pyloric  sphincter. 

B     Defect  in  the  first  portion  of  the  duodenum  due  to  ulcer  probably  brought  about  more  bj^  the  adhesions 
than  by  the  ulcer  itself. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


113 


FIGURE   1"15 


FIGURE   146 


FIGURE   147 


114  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL  LESIONS 


Figure  148 

PATIENT --POSITION:     Man,  age  39.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  and  obliteration  of  the  duodenum. 

OPERATIVE  FINDINGS :    Extensive  involvement  of  the  first  portion  of  the  duodenum  by  ulcer  and  adhesions. 

A     Pyloric  sphincter. 

B     A  small  amount  of  bismuth  retained  in  the  duodenum. 

Six  and  eight  hours  after  the  bismuth  meal,  when  the  stomach  was  empty,  this  fleck  of  bismuth  remained. 

Its  significance  is  that  that  portion  of  the  duodenum  is  normal  whereas  the  remainder  is  obliterated  by 

connective  tissue  and  adhesions. 


Figure  149 

Artist's  drawing  of  Figure  148. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS  115 


FIGURE   148 


FIGURE   149 


116  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  150 

PATIENT  — POSITION:     Man,   age  52.      Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     Chronic  ulcer  of  the  duodenum. 

A     Ulcer. 

Figure  151 
Plate  III,  colored  plate  of  Figure  150. 

Figures  152  and  152A 

The  same  case  as  Figure  150.     Lateral  view. 

Obliteration  of  the  first  portion  of  the  duodenum  due  to  ulcer. 

A     Pylorus. 

B     Area  of  ulcer. 

C     Descending  duodenum. 


\ 


i 


PLATE  III  — FIGURE  151 
CHRONIC  ULCER  OF  THE  DUODENUM 


J'^ 


THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


117 


FIGURE    150 


FIGURE  152 


FIGURE   152A 


118  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  153 

PATIENT  — POSITION:     Man,  age  38.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     Small  ulcer  of  the  posterior  wall  of  the  duodenum. 

A     Small  mucosal  defect  on  the  superior  border  of  the  duodenum. 
Note  the  poor  filling  of  the  antrum,  mostly  due  to  pressure. 


Figure  154 

The  same  case  as  Figure  153  showing  a  more  complete  filling  of  the  antrum  of  the  stomach  and  first  portion 

of  the  duodenum. 

A     Pylorus. 

B — C     Deforming  effect  of  connective  tissue  engirding  the  first  portion  of  the  duodenum. 


Figure  155 

PATIENT  — POSITION:     Woman,  age  28.     Prone. 
ROENTGEN  CONCLUSIONS:     Ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     Extensive  involvement  of  the  first  portion  of  the  duodenum  with  involvement 
of  the  stomach  and  pylorus  with  adhesions. 

A     Complete  obliteration  of  the  duodenum  and  involvement  of  the  antrum  by  adhesions. 


THE   ROENTGEN   DLIGNOSIS   OF   SURGICAL   LESIONS 


119 


FIGURE    153 


FIGURE  154 


120  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  156 

PATIENT  ^POSITION:     Woman,  age  48.     Prone. 
ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum. 
OPERATIVE  FINDINGS:     Chronic  ulcer  of  the  duodenum. 

A     Mucosal  defect  on  the  superior  border  of  the  duodenum. 
B     Contraction  due  to  scar  tissue. 
C     Pylorus. 


Figure  156A 

Same  case  as  Figure  156. 

This  shows  how  constant  is  the  deformity  of  the  duodenum. 

A     Mucosal  defect. 

B     Contraction  due  to  scar  tissue. 


Figure  157 

PATIENT  — POSITION:     Man,  age  53.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum,  obstructive  type. 

OPERATIVE  FINDINGS:     Extensive  adhesions  about  the  duodenum,  probably  ulcer.     Stomach  markedly 
dilated. 

A     Pylorus. 

This  plate  was  made  six  hours  after  the  bismuth  meal  showing  practically  no  passage  of  the  bismuth  towards 

the  small  bowel. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


121 


FIGURE   156 


FIGURE   156A 


FIGURE  1S7 


122  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  158 

PATIENT  — POSITION:     Man,  age  36.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     Chronic  duodenal  ulcer. 

A     A  filling  defect  of  the  duodenum  due  to  connective  tissue. 

B     Mucosal  defect. 

C     Incisura  opposite  the  site  of  the  ulcer. 


Figure  159 

PATIENT  — POSITION:      Woman,  age  33.     Prone. 
ROENTGEN  CONCLUSIONS:      Chronic  ulcer  of  the  duodenum. 
OPERATIVE  FINDINGS:     Ulcer  of  the  duodenum. 

A     Pylorus. 

B     Ulcer  of  the  duodenum. 

Three  years  previously  this  case  was  operated  upon  for  gall-stones. 

An  examination  of  the  stomach  at  that  time  revealed  what  was  thought  to  be  an  ulcer  on  the  lesser  curvature 

of  the  stomach  near  the  pylorus  and  the  subsequent  clinical  history  of  the  case  seemed  to  confirm  it. 

Our  examination,  however,  gave  no  Roentgen  evidence  of  gastric  ulcer  but  a  defect  in  the  first  portion  of 

the  duodenum. 

Operation  then  showed  a  duodenal  ulcer,  and  a  careful  exploration  of  the  stomach  was  made  for  a  gastric 

ulcer  but  no  evidence  of  any  could  be  found. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS  123 


FIGURE  158 


FIGURE  159 


124  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  160 

PATIENT  — POSITION:     Man,  age  38.     Prone. 

ROENTGEN  CONCLUSIONS:     Small  ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     A  very  small  ulcer  on  the  posterior  wall  of  the  duodenum. 

A     Mucosal  defect  of  an  ulcer  of  the  superior  border  of  the  duodenum. 

Figure  161 

Artist's  drawing  of  Figure  160. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


125 


FIGURE  160 


KKoenTfen  Ef  Dr  Grtorfc  \ 


126  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  162 

PATIENT  ^POSITION:     Woman,  age  36.     Prone. 

ROENTGEN  CONCLUSIONS:     Penetrating  ulcer  of  the  superior  border  of  the  duodenum. 

OPERATIVE  FINDINGS:     Confirmed  Roentgen  findings. 

A  Pylorus. 

B  Point  of  perforation  of  ulcer. 

C  The  sacculation  due  to  perforation. 

D  Incisura  on  inferior  border. 


Figure  163 

PATIENT  — POSITION:     Man,  age  28.     Prone. 

ROENTGEN  CONCLUSIONS:     Adhesions  about  the  duodenum,  stomach,  and  large  bowel. 
OPERATIVE  FINDINGS:     Involvement  of  the  stomach,  duodenum,  and  large  bowel  in  a  mass  of  adhesions. 
No  evidence  of  ulcer. 

A     Pylorus. 

B    Apparent  defect  in  first  portion  of  the  duodenum. 

C    Defect  in  antrum  of  the  stomach. 


Figure  164 

Artist's  drawing  of  Figure  163. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


127 


FIGURE   163 


128  THE  ROENTGEN   DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  165 

PATIENT  —  POSITION:     Man,  age  33.     Prone. 

ROENTGEN  CONCLUSIONS:     Hour-glass  stomach  and  beginning  gastric  ulcer  at  the  cardia. 

OPERATIVE  FINDINGS:     No  operation. 

A     Hour-glass  contraction. 

B     Pylorus. 

C     Girding  of  the  stomach  due  to  recent  ulcer  at  the  cardia. 


Figure  166 

ROENTGEN  CONCLUSIONS:     Double  hour-glass  stomach.     There  was  a  marked  increase  of  the  narrow- 
ing at  the  cardia  with  obstruction  of  the  transverse  portion  of  the  duodenum. 

A     Hour  glass  as  seen  in  first  examination. 

B     Marked  narrowing  of  the  stomach  due  to  a  new  ulcer  which  formed  a  second  hour  glass.     Pylorus 

apparently  perforated. 
C     Point  of  obstruction  at  transverse  portion  of  duodenum. 
(Note  dilatation  of  descending  portion  of  duodenum.) 

OPERATIVE  FINDINGS:     Double  hour  glass  of  the  stomach.     Ulcer  of  the  duodenum,  obstruction  of 
the  transverse  portion  of  the  duodenum  due  to  adhesions. 


Figure  167 

PATIENT  — POSITION:     Man,  age  48.     Prone. 

ROENTGEN  CONCLUSIONS:     Obstruction  of  the  transverse  portion  of  the  duodenum  due  to  adhesions. 
OPERATIVE  FINDINGS:     Extensive  involvement  of  the  head  of  the  pancreas  and  first  portion  of  the 
duodenum. 

A     Point  of  obstruction  at  the  transverse  portion  of  the  duodenum. 
B     Dilatation  of  the  descending  portion  of  the  duodenum. 


THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


129 


FIGURE   165 


130  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


Figure  168 

PATIENT  — POSITION:     Woman,  age  58.     Prone. 

ROENTGEN  CONCLUSIONS:     Fixation  of  the  first  portion  of  the  duodenum  within  the  subhepatic  region, 

probably  due  to  gall-bladder  involvement. 
OPERATIVE  FINDINGS:     Marked  dilatation  of  the  first  portion  of  the  duodenum  with  fixation  to  the 

gall-bladder  and  liver. 

A     Pylorus. 

B     First  portion  of  the  duodenum. 

C     Pressure  of  the  large  gall-bladder  upon  the  superior  border  of  the  duodenum. 


Figure  169 

PATIENT  — POSITION:     Woman,  age  37.     Prone. 

ROENTGEN  CONCLUSIONS:     Adhesions  about  the  descending  duodenum. 

OPERATIVE  FINDINGS:     Fixation  of  the  mid-portion  of  the  duodenum  to  the  gall-bladder. 

A     Point  of  fixation  of  the  duodenum. 

Figure  170 

PATIENT  — POSITION:     Woman,  age  48.     Prone. 

ROENTGEN  CONCLUSIONS:     Adhesions  about  the  second  portion  of  the  duodenum. 

OPERATIVE  FINDINGS:     Extensive   adhesions   about   the   duodenum   and   throughout   the   right  upper 
quadrant. 

A     Pulhng  effect  of  mass  of  adhesions  at  the  junction  of  the  descending  and  transverse  portions  of  the 
duodenum. 


Figure   171 

PATIENT  — POSITION:     Woman,  age  29.     Prone. 

ROENTGEN  CONCLUSIONS:     Adhesions  about  the  descending  duodenum. 

OPERATIVE  FINDINGS:     Extensive  involvement  of  the  right  upper  quadrant  with  adhesions. 

A     Pylorus. 

B     First  portion  of  the  duodenum. 

C     Showing  irregular  arrangement  of  the  second  portion  of  the  duodenum  due  to  adhesions. 

D    Beginning  of  third  portion  of  duodenum. 

Note:   This  plate  was  made  with  patient  on  the  back  on  the  plate. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL   LESIONS 


131 


FIGURE    16 


FIGURE    169 


FIGURE   170 


FIGURE   171 


132  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  172 

PATIENT  —  POSITION:     Woman,  age  38.     Prone. 

ROENTGEN  CONCLUSIONS:     Probable  ulcer  of  the  duodenum.     Possible  adhesions. 
OPERATIVE  FINDINGS:     Extensive   adhesions   about  the  first  portion   of  the  duodenum   arising  from 
gall-bladder  region  and  a  chronic  ulcer  of  the  duodenum. 

A    Antrum  of  the  stomach. 

B     First  portion  of  the  duodenum. 

This  shows  the  contraction  of  the  first  portion  of  the  duodenum  due  to  ulcer  or  adhesions  or  both. 

This  deformity  is  more  characteristic  of  extensive  adhesions  than  of  ulcer  alone. 


Figure  173 

PATIENT— POSITION:    Man,  age  60.     Prone. 
ROENTGEN  CONCLUSIONS:     Small  ulcer  of  duodenum. 
OPERATIVE  FINDINGS:     Ulcer  of  duodenum. 

A    Deformity  of  the  duodenum  due  to  connective  tissue  from  ulcer. 
B    Mucosal  defect  of  ulcer. 


THE   ROENTGEN    DIAGNOSIS   OF   SURGICAL   LESIONS 


133 


FIGURE   172 


FIGURE   173 


134  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  174 

PATIENT  — POSITION:     Man,  age  39.     Prone. 
ROENTGEN  CONCLUSIONS:     Ulcer  of  the  duodenum. 

OPERATIVE  FINDINGS:     Extensive    post-operative    adhesions    from    gall-bladder    operation    ten    years 
previously.     No  positive  evidence  of  ulcer  found. 

A     Pylorus. 

B     Contracted  area  about  the  duodenum  which  is  constant  throughout  the  series  of  plates  assumed  to  be 

contraction  about  the  ulcer. 
C     Descending  portion  of  duodenum. 
Note  in  Figures  175  and  176  how  constant  this  defect  is. 


Figure  175 
The  same  case  as  Figure  174. 
A     Pylorus. 
B     Defect  in  duodenum,  due  to  adhesions. 


Figure  176 


The  same  case  as  Figures  174  and  175. 

A     Pjdorus. 

B    Defect  in  duodenum  due  to  adhesions. 


THE   ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


135 


FIGURE    174 


FIGURE    175 


FIGURE   176 


136  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  177 

PATIENT  —  POSITION:     Premature  infant,  4  days  old.     Prone. 

ROENTGEN  CONCLUSIONS:  Obstruction  of  transverse  portion  of  duodenum,  probably  congenital 
in  origin. 

AUTOPSY:  Four  days  after  the  Roentgen  examination  autopsy  showed  marked  dilatation  of  oesophagus 
and  stomach,  and  especially  the  first  and  second  portions  of  the  duodenum  with  obstruction  due  to  a 
tumor  at  the  junction  of  the  descending  and  transverse  portions  of  the  duodenum.  The  lumen  of  the 
bowel  would  allow  only  a  small  probe. 

A    Dilatation  of  the  oesophagus. 

B     Cardia. 

C— D    Stomach. 

E    First  portion  of  the  duodenum. 

F    Obstruction  of  the  descending  portion. 


Figure  178 

The  same  case  as  Figure  177  taken  twenty-four  hours  after  the  bismuth  meal. 

This  shows  the  passage  of  but  a  very  small  amount  of  bismuth  into  the  small  bowel. 

A    CEsophagus. 

B     Cardia. 

C— D    Stomach. 

E    Point  of  obstruction  and  dilatation  of  the  duodenum. 

F     Slight  amount  of  bismuth  in  the  small  bowel. 


Figure  179 

Lateral  view  of  the  same  case  as  Figures  177  and  178. 

This  shows  the  passage  of  a  stomach  tube  in  an  effort  to  remove  the  gastric  contents. 


Figure  180 

The  same  case  as  Figures  177,  178  and  179. 

A    The  patient  is  lying  on  the  back  and  this  shows  the  passage  of  the  stomach  tube  through  the  pylorus. 

B — C     Stomach  tube  following  along  greater  curvature  toward  cardia  instead  of  pyloric  region. 

D     Dilated  duodenum. 

E     Bismuth  in  jejunum  and  ileum. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


137 


FIGURE   177 


FIGURE  178 


FIGURE  180 


138  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  181 

PATIENT  — POSITION:     Man,  age  62.     Prone. 

ROENTGEN  CONCLUSIONS:     Primary  carcinoma  of  the  duodenum. 

OPERATIVE  FINDINGS:     Extensive  involvement  of  the  first  portion  of  the  duodenum  with  inflammatory 
tissue  considered  at  the  time  of  operation  to  be  chronic  ulcer. 

The  autopsy  showed  an  extensive  involvement  of  the  duodenum  by  carcinoma. 

A     Pylorus. 

B — B — B     Multiple  areas  of  involvement  in  the  first  portion  of  the  duodenum. 

C     Extension  of  this  portion  into  the  antrum  of  the  stomach  along  the  greater  curvature. 

The  multiphcity  of  filling  defects  is  not  characteristic  of  chronic  ulcer. 

The  same  defect  is  found  in  the  duodenum  and  extends  to  the  greater  curvature  of  the  stomach. 

At  autopsy  this  proved  to  be  partly  pressure  due  to  new  growth. 

D    A  loop  of  jejunum  fixed  above  the  stomach  by  adhesions. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS  139 


FIGURE    181 


140  THE   ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


SECTION  V 


GALL-BLADDER 

Percentage  of  Stones  which  Show  —  Technique  —  Preparation  and  Position 

OF    Patient,  Tubes,  Plates,  Screens,  Stereoscopic  Plates  — 

Demonstration  of  Diseased  Gall-Bladder  —  Adhesions 


Up  to  three  years  ago  gall-stones  were  detected  by  the  Roentgenologist  in  such  a 
small  percentage  of  the  suspected  cases  that  most  Roentgenologists  did  not  recommend  the 
examination  and  only  made  it  when  urged  to  do  so.  Several  of  us,  however,  found  that 
gall-stones  containing  calcium  could  be  detected  much  more  frequently  than  we  had  sup- 
posed, and  this  discovery  stimulated  the  search.  While  as  yet  few  Roentgenologists  have 
published  reports,  the  general  opinion  seems  to  be  that  from  fifty  to  seventy-five  per  cent 
of  gall-stones  will  show.  With  our  present  technique  we  feel  that  eighty-five  to  ninety  per 
cent  can  be  demonstrated.  This  percentage  naturally  increased  the  value  of  the  negative 
plate. 

TECHNIQUE 

The  technique  is  not  radically  different  from  that  employed  for  soft  tissue  work  in 
any  other  part  of  the  body;  but  it  requires  conscientious  attention  to  the  most  minute 
points.  One  must  not  be  satisfied  with  the  plates  unless  detail  is  shown  to  the  greatest 
possible  degree.  Roentgen  plates  obtained  by  improved  technique  show  extraordinary 
detail.  In  two  cases  the  pelvis  of  the  kidney,  the  blood  vessels  going  to  and  from  it,  and 
the  upper  part  of  the  ureter  were  remarkably  distinct. 

Opinions  differ  as  to  the  advisability  of  catharsis  prior  to  the  examination.  The  writers 
consider  that  the  gas  resulting  from  the  cathartic  is  a  more  disturbing  factor  in  the  inter- 
pretation of  the  Roentgen  plate  than  the  fecal  contents  of  the  colon. 

The  vast  improvement  in  tube  construction  which  has  been  made  in  recent  years 
enables  one  to  obtain  an  accuracy  and  degree  of  penetration  which  has  hitherto  been  unat- 
tainable practically.  Roentgen  plates  showing  brilliant  bone  detail  with  considerable  density 
of  the  soft  parts  are  not  desirable  for  the  diagnosis  of  gall-stones. 

Soft  "monotonic"  Roentgen  plates  obtained  with  the  later  model  tubes  are  deprecated  by 
some  critics  because  marked  contrast  in  the  bony  strueti*Fe  is  lacking;   but  they  show  re- 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS  141 

markable  graduations  in  the  soft  tissue  —  a  result  for  which  one  strives  when  in  search  of 
gall-stones. 

Minor  condemned  fine  Roentgen  plates  of  the  lungs  as  compared  with  the  fluoroscopic 
image  because  they  showed  so  much  detail  in  the  soft  parts  as  to  make  them  difficult  to 
interpret.  It  is  the  interpretation  of  these  very  details  that  increases  the  accuracy  of 
diagnosis,  whether  it  be  the  chest  or  gall-bladder  that  is  under  consideration. 

The  necessity  of  using  an  extremel.y  small  cone,  showing  only  a  limited  area  in  each 
Roentgen  plate,  is  strongly  emphasized.  The  length  of  the  cone  is  not  an  essential  factor. 
By  means  of  such  a  cone  secondary  rays  are  generated  in  the  patient  to  a  much  less  degree, 
and  the  fogging  effect  being  proportionately  diminished  it  is  then  possible  to  show  dis- 
tinctly a  calculus  that  would  be  quite  invisible  if  a  large  or  moderate-sized  blend  were  used. 
The  cone  may  be  pointed  obliquely  downward  so  that  the  axis  of  the  rays  is  parallel  with 
the  under  surface  of  the  liver.  When-  this  is  done,  the  under  surface  of  the  liver  appears 
as  a  clear-cut  and  well-defined  line;  and  the  gall-bladder,  if  normal,  can  usuallj^  be  detected, 
or  the  relation  of  the  patient  to  the  tube  may  be  altered  by  a  slight  rolling  from  side  to 
side.  Sometimes,  particularly  when  the  gall-bladder  is  high,  a  lateral  position  will  show  the 
gall-stones  against  the  background  of  the  liver. 

It  matters  very  little  whether  screened  or  unscreened  plates  are  used.  Some  plates 
may  be  made  with  screens,  and  some  without  them.  The  unscreened  plates  should  be  ex- 
posed face  to  face,  and  shghtly  undertimed,  with  a  view  to  matching  up  the  shadows  thereon 
after  development.  Double  screened  plates  also  may  be  made  in  a  special  holder,  con- 
structed to  carry  screens  of  different  rapidity.  Two  plates  and  two  screens  of  different 
speed  are  used  in  the  same  holder.  The  plates  are  placed  back  to  back.  The  under  one, 
face  down,  lies  against  a  fast  screen,  whilst  the  upper  one  lies  face  upward  against  a  rela- 
tively slow  and  thin  screen.  A  very  short  or  even  undertimed  exposure  is  made,  and  after 
development  the  plates  are  superimposed  and  matched  together,  whereupon  by  transmitted 
light  one  gets  the  plastic  effect  up  to  a  certain  point.  This  method  ehminates  screen  and 
plate  defects  to  a  great  extent. 

Roentgen  stereoscopy  adds  very  materially  in  the  interpretation  of  the  Roentgen  plates. 
Four  exposures  may  be  made,  preferably  with  each  exposure  on  the  two  plates  face  to  face, 
giving  a  slight  lateral  shift  to  the  tube  between  the  first  and  second  exposures.  Then  move 
the  tube  down  about  two  inches  and  make  two  more  exposures,  shifting  the  tube  once 
more  in  the  lateral  direction  between  the  third  and  fourth.  In  this  manner,  one  can  stereo- 
scope the  various  exposures  with  each  other,  that  is  to  say,  1-2  and  3-4  stereoscoped  with 
each  other  laterally,  and  1-3  and  2-4  stereoscoped  with  each  other  vertically. 


DEMONSTRATION   OF  DISEASED   GALL-BLADDER 

Comparison  from  behind  avails  little;  but  small  areas  may  be  brought  close  to  the 
plate  for  detailed  examination,  by  the  use  of  a  circular  plate  holder  about  the  size  of  the 
end  of  a  small  compression  blend.  This  holder,  with  or  without  a  screen,  may  be  pushed 
up  under  the  edge  of  the  rib,  thereby  materiallj^  diminishing  the  thickness  of  that  part  of 
the  abdomen. 

The  entire  region  from  the  eleventh  rib  to  the  crest  of  the  ileum,  or  even  lower,  should 
be  included  in  the  examination.  As  repeated  exposures  are  required,  and  as  some  of  the 
plates  are  not  screened,   the  total  exposure  is  considerable,   and  a  filter  should  always  be 


142  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 

used  to  prevent  dermatitis.  If  after  carefiil  study  of  at  least  fifteen  or  twentj^  Roentgen 
plates  of  the  gall-bladder,  no  evidence  of  the  calculi  is  found,  the  patient  should  be  sub- 
mitted to  an  examination  of  the  stomach,  duodenima,  and  colon,  in  a  search  for  adhesions 
from  cholecystitis  -ndthout  stones,  or  for  the  purpose  of  differentiating  this  condition  from 
post-pyloric  ulcer  and  appendicitis  with  reflex  gastric  symptoms. 

Even  when  there  is  direct  evidence  of  the  stone,  this  additional  information  is  of  great 
value  in  determining  whether  or  not  there  is  a  concomitant  lesion,  whether  or  not  surgery 
is  indicated  and  how  difficult  the  operation  may  be. 

Although  the  technique  herein  described  greatly  facihtates  the  interpretation  of  the 
Roentgen  plates,  gall-stones  may  be  detected  in  the  ordinary  Roentgen  plate  in  a  large 
percentage  of  cases  if  one  is  familiar  with  their  Roentgen  appearance. 

ADHESIONS 

Of  late,  a  re-examination  has  been  made  of  those  Roentgen  plates  taken  during  the 
last  four  or  five  years  in  which  direct  evidence  of  gall-stones  was  insufficient  or  undetected, 
but  which  showed  enough  evidence  of  adhesions  from  the  accompamdng  cholecj^stitis  to 
justify  surgical  procedure.  In  the  re-examination,  our  increased  knowledge  of  the  Roentgen 
appearance  of  soft  gall-stones  has  enabled  us  to  detect  direct  evidence  of  the  calculus  on 
the  Roentgen  plate,  in  a  large  number  of  cases  where  calculus  was  found  at  operation. 

The  same  results  have  been  obtained  from  a  restudj^  of  those  cases  where  the  gall- 
bladder onl}^  was  examined,  and  a  negative  diagnosis  was  made.  The  gall-stones  found  at 
operation  in  these  patients  can  now  be  identified  in  the  original  Roentgen  plates.  The 
evidence  was  there  before,  but  we  were  then  unable  to  recognize  it. 

Of  all  the  aids  to  be  suggested  for  detecting  calciili,  the  method  of  matching  together 
the  shadows  by  superimposing  one  Roentgen  plate  over  another  is  probably  the  most  im- 
portant. By  far  the  best  illumination  can  be  obtained  by  holding  the  plate  obliquely  at 
an  arm's  length  against  a  northern  light.  A  concave  lens,  or  better  stiU  a  pair  of  opera 
glasses,  used  in  the  reverse  direction  wall  accentuate  contrasts.  For  examining  a  small  area 
a  magnifpng  glass  may  be  helpful,  especially  in  identifying  the  faceted  side  of  small  calcuh. 

A  lantern  slide  made  of  superimposed  Roentgen  plates  will  sometimes  accentuate  the 
contrast  and  bring  out  details  not  observed  in  the  original  plates.  Thus  very  faint  shadows 
may  sometimes  be  shown  w^ell  enough  for  lantern  slide  demonstration  or  reproduction; 
whereas  others  cannot  be  demonstrated  or  reproduced  for  publication  because  the  shadows 
concentrated  on  the  shdes  are  diffused  by  enlargement. 

Identification  of  the  gall-bladder  aids  materially  in  the  detection  of  calculi,  and  is  a 
detail  which  one  should  alwaj^s  try  to  obtain.  It  can  be  detected  in  nearly  every  case 
where  it  exists  normal  in  size  or  dilated.  The  gall-bladder  may  be  found  anjTvhere  from 
the  region  of  the  eleventh  rib  to  the  fifth  lumbar  vertebra.  In  one  case,  it  was  located  as 
far  down  as  the  sacrimi.  As  a  rule,  it  will  be  seen  below  the  lower  border  of  the  liver.  If, 
after  taking  a  number  of  Roentgen  plates,  the  gall-bladder  is  not  found  in  the  normal 
position,  it  can  sometimes  be  located  when  a  subsequent  bismuth  examination  is  made  by 
noting  the  position  of  the  transverse  colon. 

GaU-stones  are  divided  into  two  definite  groups:  (1)  Stones  which  contain  considerable 
calcium,  and  (2)  cholesterine  stones  which  contain  no  calcium,  or  only  a  trace  of  it.  Gall- 
stones containing  a  large  proportion  of  calcium  can  be  shown  without  much  difficulty  and 
are  sometimes  so  dense  as  to  be  mistaken  for  renal  calculi. 


THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS  143 

The  dense  calcareous  gall-stones  are  a  type  of  calculi  infrequently  found;  this  perhaps 
explains  why  the  study  of  gall-stones  has  made  little  advance  since  thej^  were  first  observed. 
Bj^  far  the  greater  number  of  gall-stones  consist  of  cholesterine  nucleus,  with  a  calcareous 
coating,  or  vice  versa.  When  the  peripheral  concretions  are  thin,  which  is  true  in  about 
fifty  per  cent  of  the  cases,  the  stones  are  difficult  to  detect.  With  increasing  density  of 
the  coating,  the  ring-like  appearance  is  proportionally  more  marked  and  relatively  easier 
to  discover;  but  it  is  probably  safe  to  say  that  the  absolutely  pure  cholesterine  stone  is  a 
rare  entity. 

Unless  unusual  care  is  used  in  making  and  interpreting  Roentgen  plates,  cholesterine 
stones  containing  only  a  trace  of  calcium  will  be  entirely  overlooked  in  the  future,  just  as 
they  have  escaped  observation  in  the  past.  It  is  not  the  shadow-producing  quality  of  the 
stone  as  a  whole  that  concerns  us  in  this  class  of  case,  but  rather  the  shadow  cast  by  the 
long  diameter  of  the  periphery  of  the  stone.  Whether  the  stone  be  faceted,  spherical  or  a 
combination  of  both,  in  some  particular  diameter  there  will  be  sufficient  density  to  cast  a 
peripheral  shadow.  This  explains  in  part  why  a  single  Roentgen  plate  of  a  series  will  often 
reveal  a  perfectly  characteristic  gall-stone,  whereas  all  previous  plates  of  the  same  region 
show  only  questionable  shadows.  If  each  individual  stone  in  a  mass  of  small  stones  does  not 
cast  a  well-defined  shadow,  the  shadow  of  the  entire  mass  will  often  give  the  clue. 

The  interpretation  of  suggestive  shadows  in  the  region  of  the  gall-bladder  is  fraught 
with  difficulties,  similar  to  those  experienced  when  positive  diagnosis  of  kidney  stones  was 
first  attempted.  The  present  accuracy  in  diagnosing  renal  stones  is  the  result  of  experience 
gained  through  numerous  errors.  Some  of  the  disturbing  factors  in  the  gall-bladder  region, 
such  as  intestinal  contents,  calcified  mesenteric  glands,  costo-chondral  ossification,  and  stones 
in  the  kidney  and  liver,  have  been  enumerated  in  previous  articles.  Recent  experience  has 
added  to  our  knowledge  of  possible  pitfalls.  Food  in  the  first  portion  of  the  duodenum 
is  a  particularly  confusing  finding,  because  its  density  corresponds  to  the  faint  shadow  of 
a  stone,  and  its  size  and  position  add  to  the  illusion.  Upon  minute  examination,  however, 
it  will  be  found  that  the  shadow  of  food  lacks  the  ring-hke  circumference  of  the  choles- 
terine stone  with  a  calcareous  shell;  neither  has  it  the  homogeneous  character  of  the  calcium 
stone,  but  is  rather  mottled  in  appearance.  Moreover,  it  is  usually  possible  to  completely 
identify  the  shadow  by  tracing  the  outlines  of  the  adjoining  pars  pylorica.  Where  the  shad- 
ows are  obscure  several  Roentgen  plates  matched  together  will  increase  the  density.  A 
disturbing  element  of  the  same  character  is  food  contained  in  a  single  haustrum  of  the  colon 
at  the  hepatic  flexure.  Being  broad  at  one  end  and  tapering  to  a  fine  point  at  the  other  end,  it 
resembles  an  almond-shaped  calculus.    Abstinence  from  food  eliminates  results  from  this  error. 

Another  interesting  finding,  and  one  which  is  visible  only  to  the  eye  trained  to  pick 
up  the  slightest  variation  in  density,  is  the  presence  of  little  rings,  often  no  larger  than  a 
good-sized  pinhead,  sometimes  found  in  groups,  sometimes  isolated,  in  varying  shapes  of 
round,  oval  or  even  quite  irregular  form.  It  is  quite  possible  that  these  infinitesimal  find- 
ings are  the  walls  of  blood  vessels  seen  in  cross  section. 

It  is  a  mistake  to  study  Roentgen  plates  when  they  are  wet,  not  only  because  reflected 
light  cannot  be  avoided,  but  also  because  there  is  risk  of  damaging  the  plate. 

A  careful  study  of  the  clinical  history  of  cases  in  which  gall-stones  are  definitely  shown 
by  Roentgen  methods  reveals  the  futility  of  expecting  the  classical  gall-bladder  symptoms 
to  agree  with  the  Roentgen  diagnosis. 

Before  the  advent  of  the  X-ray,  renal  colic  and  renal  calculi  were  considered  almost 
synonymous  terms.    But  surgical  procedure  for  renal  colic  in  cases  where  no  calculus  was 


144  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 

shown  on  the  Roentgen  plate  eventually  proved  that  only  about  one-fourth  of  the  cases 
having  typical  attacks  of  renal  colic  had  a  calculus  of  sufficient  size  to  be  found  by  surgical 
exploration.  On  the  other  hand,  only  about  one-fourth  of  the  cases  in  which  kidney  stones 
were  definitely  demonstrated  by  Roentgen  methods  had  anything  simulating  renal  cohc. 

Our  present  experience  indicates  that  the  same  observation  will  hold  true  in  the  gall- 
bladder region;  that  only  when  a  gall-stone  passes  or  engages  does  it  cause  the  typical  gall- 
stone cohc,  and  this  is  relatively  rare  compared  with  the  frequency  of  gall-stones. 

The  chnical  indications  of  cholecystitis  compare  with  those  of  pyelitis,  except  that  one 
does  not  detect  the  presence  of  pus  in  the  stools  as  readily  as  one  detects  it  in  the  urine. 
Some  of  the  cases  of  gall-stones  give  practically  no  characteristic  symptoms  of  gall-stones, 
but  are  associated  with  obscure  gastric  or  neurotic  symptoms. 

Therefore,  any  case  presenting  gastro-intestinal  symptoms  with  absence  of  Roentgen 
evidence  of  an  organic  lesion  of  the  stomach  or  intestines  should  be  submitted  to  a  careful 
Roentgen  examination  of  the  gall-bladder.  This  is  particularly  true  if,  as  Deaver  suggests, 
the  patient  is  "fair,  fat  and  forty  and  belches  gas." 

It  is  much  easier  to  detect  the  stone  in  this  class  of  case  than  in  thin,  wiry,  poorly 
nourished  people  who  have  no  fat  to  outhne  the  gall-bladder,  and  whose  muscle  is  nearly 
as  dense  as  bone.  In  persons  under  twenty-five,  the  peripheral  coating  of  the  stone  is  not 
usually  dense,  and  the  stone  is  so  soft  that  it  does  not  show  even  a  dim  peripheral  ring  or 
edge.  Post-operative  cases  with  extensive  adhesions,  carcinoma  of  the  liver  or  gall-bladder, 
and  ascites  also  render  negative  diagnosis  exceedingly  difficult  if  not  impossible. 

Diagnostic  accuracy  is  directly  in  proportion  to  the  care  exercised  in  making  the  ex- 
amination, and  one's  experience  in  detecting  and  interpreting  the  findings.  Statistics  are  of 
little  value  until  thousands  of  cases  have  been  observed  by  methods  as  careful  and  detailed 
as  those  described  above.  By  that  time  the  value  of  the  method  wiU  be  generally  acknowl- 
edged, and  statistics  will  not  count  for  any  more  than  they  do  now  in  cases  of  renal  calcuh 
or  fractures. 

The  Roentgen  method  of  diagnosing  gall-stones  has  become  so  accurate  that  if  there 
is  no  direct  Roentgen  evidence  of  gall-stones,  or  indirect  evidence  of  adhesions  involving 
the  stomach,  cap,  duodenum  or  colon,  as  a  result  of  cholecystitis,  the  surgeon  should  have 
a  preponderance  of  chnical  evidence  as  a  warrant  in  operating  for  gall-stones. 

RESUME 

1.  Until  within  three  or  fom-  years,  gall-stones  were  rarely  detected  by  Roentgen  rays. 

2.  During  the  last  few  years  several  Roentgenologists,  including  ourselves,  consider 
that  they  have  detected  gall-stones  in  from  fifty  to  eighty-five  per  cent  of  the  cases  examined. 
This  was  estimated  in  different  ways  by  different  men. 

3.  Experience  has  shown  that  gall-stones  may  be  detected  about  twice  as  frequently 
as  formerly  by:  (a)  A  special  technique  for  making  the  Roentgen  plates;  (b)  a  minutely  care- 
ful study  of  the  Roentgen  plates  by  various  methods;  (c)  a  thorough  intimacy  with  the 
Roentgenographic  appearance  of  gall-stones. 

4.  By  applying  the  new  method  of  interpretation,  gall-stones  have  been  detected  on 
many  Roentgen  plates  made  by  the  old  technique  and  formerly  diagnosed  as  negative. 

5.  By  means  of  the  special  technique  for  making  and  interpreting  Roentgen  plates,  a 
positive  diagnosis  may  be  made  in  so  many  cases  that  the  negative  diagnosis  has  become 
of  considerable  significance. 


THE   ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS  145 

6.  Much  care  and  study  will  be  necessary  to  properly  interpret  the  additional  detail 
which  can  be  obtained  by  the  special  technique  and  undoubtedly  some  erroneous  diagnoses 
will  be  made.  (Cole  has  made  two  such  erroneous  diagnoses,  and  has  thereby  learned  to 
differentiate  the  food  in  the  cap  and  the  feces  in  the  haustra  of  the  colon  from  evidence  of 
calculi,  a  most  difficult  problem.) 

7.  If  there  is  no  direct  Roentgen  evidence  of  gall-stones,  the  stomach,  cap,  duodenum 
and  colon  should  be  examined  for  adhesions  from  an  accompanying  cholecystitis. 

8.  If  there  is  no  direct  or  indirect  Roentgen  evidence  of  gall-stones,  the  clinical  history 
should  be  more  characteristic  than  usual  before  one  resorts  to  surgical  procedure. 


146  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


GALL-BLADDER 

Figure  182 

PATIENT  —  POSITION:     Woman,  age  28.     Prone. 

ROENTGEN  CONCLUSIONS:  Gall-stones.  Gastric  ulcer.  Duodenum  fixed  in  the  upper  right  quad- 
rant. 

OPERATIVE  FINDINGS:  Gall-stones.  Fixation  of  duodenum  to  gall-bladder.  Adhesion  about  antrum 
of  stomach. 

A     Faint  shadow  caused  by  increased  density  in  the  gall-bladder  region. 

B     Ulcer  of  the  stomach  near  the  pylorus. 

C     A  portion  of  the  descending  duodenum  fixed  in  the  subhepatic  region. 


Figure  183 

Artist's  drawing  made  at  the  time  of  operation.     (See  Figure  182.) 

Adhesions  between  the  descending  duodenum  and  gall-bladder. 

The  cystic  duct  is  full  of  small  stones.     The  lesion  in  the  stomach  is  an  adhesion,  probably  due  to  old 

ulcer  of  the  lesser  curvature,  posterior  wall. 


Figure  184 

PATIENT  —  POSITION:     Woman,  age  33.     Prone. 
ROENTGEN  CONCLUSIONS:     Gall-stones. 
OPERATIVE  FINDINGS:     A  large  number  of  gall-stones. 

A    Cystic  duct  filled  with  inspissated  bile. 

B     One  or  more  small  gall-stones  scattered  through  the  duct. 

C     Gall-bladder  full  of  stones. 


Figure  185 

Same  as  Figure  184. 

This  plate  was  made  three  months  later  and  shows  no  evidence  of  inspissated  bile  in  the  cystic  duct.  The 
patient  had  had  several  attacks  between  the  first  and  second  examinations.  This  plate  shows  the  gall- 
bladder full  of  various  sized  calculi,  making  it  chfKcult  to  define  individual  stones. 

A    Gall-bladder. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


147 


FIGURE  182 


FIGURE  183 


FIGURE    184 


FIGURE   185 


148  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  186 

PATIENT  —  POSITION:     Woman,  age  23.     Prone. 
ROENTGEN  CONCLUSIONS:     Gall-stones. 
OPERATIVE  FINDINGS:     Thirty-seven  small  calculi. 

A     Gall-bladder  full  of  small  stones. 

B     Effect  of  pressure  of  the  gall-bladder  on  antrum  of  the  stomach. 


Figure  187 

PATIENT  —  POSITION:  Woman,  age  40.  Prone. 
ROENTGEN  CONCLUSIONS:  A  large  gall-stone. 
OPERATIVE  FINDINGS:     One  large  gall-stone. 

A    One  cholesterine  stone  about  the  size  of  a  fifty-cent  piece. 

Diagnosed  Roentgenographically  by  the  peripheral  shadow. 

This  could  not  be  diagnosed  in  the  gall-bladder  series  of  plates  vdth  certainty,  but  after  a  bismuth  meal 

the  stone  was  held  in  such  a  position  that  it  could  be  easily  detected  on  the  Roentgen  plate. 


Figure  1{ 

PATIENT  —  POSITION:     Woman,  age  40.     Prone. 
ROENTGEN  CONCLUSIONS:     Two  gall-stones. 
OPERATIVE  FINDINGS:     Gall-stones. 

A — B     Outline  of  two  gall-stones. 


THE   ROENTCxEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


149 


FIGURE   186 


FIGURE   187 


FIGURE   188 


150  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  189 

PATIENT  — POSITION:     Woman,  age  35.     Prone. 

ROENTGEN  CONCLUSIONS:     A  mass  of  gall-stones. 

OPERATIVE  FINDINGS:     A  mass  of  forty-seven  gall-stones.     One  found  in  cystic  duct. 

A     Gall-bladder  full  of  gall-stones. 

This  plate  also  illustrates  the  singularly  low  position  of  the  gall-bladder. 

One  gall-stone  faintly  seen  lying  close  to  the  spine  which  was  thought  to  be  in  the  cystic  duct.     This  was 

proven  at  operation. 

This  case  presents  one  noteworthy  fact.     A  gall-bladder  in  this  position  may  give  rise  to  clinical  symptoms 

simulating  appendicitis.     Indeed  this  patient  had  had  an  appendectomy  without  relief  of  her  symptoms. 


Figure  189 A 

Same  case  as  Figure  189. 

This  plate  made  without  an  intensifying  screen. 


Figure  190 

PATIENT  —  POSITION :     Woman,  age  52.     Prone. 
ROENTGEN  CONCLUSIONS:     Two  large  gall-stones. 
OPERATIVE  FINDINGS:     Two  large  gall-stones. 


A — B    Two  large  dense  gall-stones. 

Figure  191 

PATIENT  — POSITION:     Woman,  age  35.     Prone. 
ROENTGEN  CONCLUSIONS:     Gall-stones. 
OPERATIVE  FINDINGS:     Two  large  gall-stones. 

A — B     Peripheral  shadows  which  represent  a  large  number  of  gall-stones;  though  no  individual  gall-stone 
is  distinct,  the  collection  of  gall-stones  shows  positively  on  the  Roentgen  plate. 


THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


151 


FIGURE   189 


FIGURE   189A 


FIGURE    190 


FIGURE    191 


152  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  192 

PATIENT  — POSITION:     Woman,  age  48.     Prone. 
ROENTGEN  CONCLUSIONS:     One  large  gall-stone. 
OPERATIVE  FINDINGS:     One  large  gall-stone. 

A    Gall-stone. 


Figure  193 

PATIENT  —  POSITION:     Woman,  age  40.     Prone. 

ROENTGEN  CONCLUSIONS:     Probable  gall-stones. 

OPERATIVE  FINDINGS:     Gall-bladder  full  of  very  small  gall-stones  and  a  large  number  of  cholesterine 
crystals. 

A — B     Calcareous  material  in  the  gall-bladder  which  was  distinct  from  the  shadows  produced  by  the  costal 
border.     The  Roentgen  conclusions  should  have  been  "pathological  gall-bladder." 


Figure  194 

PATIENT  —  POSITION:     Man,  age  45.     Prone. 
ROENTGEN  CONCLUSIONS:     One  large  gall-stone. 
OPERATIVE  FINDINGS:     One  gall-stone. 

A    Peripheral  shadow  of  a  large  gall-stone. 

Note  that  the  nucleus  is  no  denser  than  the  surrounding  tissue,  although  a  portion  of  it  overhes  the  rib. 

The  patient  weighed  over  200  pounds. 


Figure  195 

PATIENT  —  POSITION:     Woman,  age  80.     Prone. 
ROENTGEN  CONCLUSIONS:     Several  large  gall-stones. 

OPERATIVE  FINDINGS:     Two  gall-stones  the  size  of  small  eggs  and  about  twenty  others  varying  in  size 
from  a  ten-cent  piece  to  a  quarter. 

A     Outhne  of  the  largest  gall-stone. 
B     Outline  of  a  gall-stone. 


THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


153 


A/ 


FIGURE   192 


FIGURE  193 


FIGURE   194 


FIGURE    195 


154  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  196 

PATIENT —  POSITION:     Woman,  age  32.     Prone. 

ROENTGEN  CONCLUSIONS:     Two  small  gall-stones. 

OPERATIVE  FINDINGS:     Two  small  gall-stones  and  various  small  stones. 

A     Definite  peripheral  shadow  produced  by  two  stones. 


Figure  197 

PATIENT  —  POSITION:     Woman,  age  62.     Prone. 
ROENTGEN  CONCLUSIONS:     One  gall-stone. 
OPERATIVE  FINDINGS:     One  large  gall-stone. 

A    One  large  gall-stone. 


Figure  198 

PATIENT  —  POSITION:     Woman,  age  32.     Prone. 
ROENTGEN  CONCLUSIONS:     One  gall-stone,  probably  others. 
OPERATIVE  FINDINGS:     Four  gall-stones. 

A     One  stone  which  made  the  diagnosis  positive.     In  the  original  plate  shadows  were  seen  which  suggested 
other  stones. 


Figure  199 

PATIENT  — POSITION:     Woman,  age  28.     Prone. 

ROENTGEN  CONCLUSIONS:     Probably  gall-stones  in  the  common  duct. 

OPERATIVE  FINDINGS:     Cholecystitis  with  very  small  gall-stones  in  the  gall-bladder.     One  moderate 
size  gall-stone  found  in  the  common  duct. 

A     Suspicious  area  in  the  region  of  the  common  duct. 


THE   ROEXTGEX   DIAGNOSIS   OF    SURGICAL   LESIONS 


155 


FIGURE  196 


FIGURE   197 


k\ 


FIGURE    19 


FIGURE   199 


156  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


Figure  200 

PATIENT  — POSITION:     Man,  age  42.     Prone. 

ROENTGEN  CONCLUSIONS:     Pathological  gall-bladder  with  probable  gall-stones. 

OPERATIVE  FINDINGS:     Very  large  and  thickened  gall-bladder  containing  a  large  number  of  gall-stones. 

A     Gall-bladder  outlined  very  definitely  and  shows  increased  density. 
B     Lower  border  of  the  gall-bladder. 


Figure  201 

PATIENT  — POSITION:     Woman,  age  43.     Prone. 
ROENTGEN  CONCLUSIONS:     Group  of  small  gall-stones. 
OPERATIVE  FINDINGS:     Large  number  of  small  dense  gall-stones. 

A — B     Position  of  the  gall-bladder  containing  gall-stones. 


Figure  202 

PATIENT  — POSITION:     Man,  age  48.     Prone. 

ROENTGEN  CONCLUSIONS:     Two  small  gall-stones. 

OPERATIVE  FINDINGS:     Gall-stones. 

A — B     Gall-stones. 

See  Figure  281  showing  a  pathological  appendix. 


Figure  203 


PATIENT  — POSITION:     Man,  age  40.     Prone. 
ROENTGEN  CONCLUSIONS:     One  gall-stone. 
OPERATIVE  FINDINGS:     One  gall-stone. 

A    OutUne  of  one  gall-stone. 

This  patient  weighed  over  200  pounds. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


157 


FIGURE  200 


FIGURE   201 


FIGURE   202 


FIGURE  203 


158  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  204 

PATIENT  — POSITION:     Woman,  age  48.     Prone. 
ROENTGEN  CONCLUSIONS:     Probable  gall-stones. 
OPERATIVE  FINDINGS:     Two  small  gall-stones. 

A    Dense  area  in  the  region  of  the  gall-bladder  which  was  supposed  to  be  material  in  the  gall-bladder. 
This  proved  in  the  operation  to  be  two  small  mulberry  gall-stones  adherent  to  one  another. 


Figure  205 

PATIENT  — POSITION:     Woman,  age  50.     Prone. 

ROENTGEN  CONCLUSIONS:     Pressure  of  large  gall-bladder  on  first  portion  of  the  duodenum. 

OPERATIVE  FINDINGS:     Pathological  gall-bladder.     No  gall-stones.     Adhesions  about  the  stomach,  duo- 
denum and  gall-bladder. 

A    Pressure  of  gall-bladder  on  the  bismuth  mass  in  the  duodenum.     After  repeated  plates  the  opinion  was 
passed  that  there  was  probably  a  pathological  gall-bladder  and  no  Roentgen  evidence  of  gall-stones. 


Figure  206 

PATIENT  — POSITION:     Man,  age  48.     Prone. 
ROENTGEN  CONCLUSIONS:     One  gall-stone. 
OPERATIVE  FINDINGS:     One  large  soft  gall-stone. 

A    Outhne  of  one  or  more  gall-stones. 


Figure  207 

PATIENT  — POSITION:     Man,  age  56.     Prone. 
ROENTGEN  CONCLUSIONS:     One  gall-stone. 
OPERATIVE  FINDINGS:     One  gall-stone. 

A     Very  distinct  gall-stone  in  individual  weighing  200  pounds. 


THE   ROEXTGEX   DIAGX05IS    OF   SURGICAL   LESIOXS 


159 


FIGURE    204 


FIGURE   205 


FIGURE  206 


FIGURE  207 


160  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  208 

PATIENT  — POSITION:     Man,  age  28.     Prone. 
ROENTGEN  CONCLUSIONS:     Gall-stones. 
OPERATIVE  FINDINGS:     Gall-stones. 

A    Outline  of  one  gall-stone. 

This  case  was  previously  examined  for  renal  calculus.  There  was  a  shadow  found  in  the  region  of  the 
right  kidney.  Patient  was  operated  upon  and  no  kidney  stone  found.  After  another  Roentgen  ex- 
amination the  same  shadow  was  found  and  proved  to  be  a  gall-stone. 


Figure  209 

PATIENT  — POSITION:     Man,  age  58.     Prone. 

ROENTGEN  CONCLUSIONS:     Large  number  of  small  gall-stones. 

OPERATIVE  FINDINGS:     Sixty-seven  small  gall-stones. 

A    Outhne  of  largest  gall-stone. 

B — C    Indistinct  shadow  of  gall-stones. 


Figure  210 

PATIENT  — POSITION:     Woman,  age  36.     Prone. 
ROENTGEN  CONCLUSIONS:     Gall-stones. 
OPERATIVE  FINDINGS:     Large  number  of  gall-stones. 

A    One  of  the  largest  gall-stones. 
B— C— D     Other  gall-stones. 
This  patient  weighed  214  pounds. 


Figure  211 

PATIENT  — POSITION:     Woman,  age  40.     Prone. 
ROENTGEN  CONCLUSIONS:     Gall-stones. 
OPERATIVE  FINDINGS:     Several  gall-stones. 

A     Outhne  of  one  gall-stone  which  made  the  diagnosis  positive. 
B     Outline  of  other  gall-stones  and  gall-bladder. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


161 


FIGURE   208 


FIGURE  209 


FIGURE  210 


FIGURE  211 


162  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  212 

PATIENT  —  POSITION:     Woman,  age  70.     Prone. 
ROENTGEN  CONCLUSIONS:     Group  of  small  gall-stones. 
OPERATIVE  FINDINGS:     Gall-stones. 

A    Group  of  eighteen  small  gall-stones  the  size  of  millet  seeds. 

This  case  was  examined  for  new  growth  of  the  large  bowel  and  the  gall-stones  were  found  accidentally. 

There  was  no  evidence  of  new  growth. 


Figure  213 

PATIENT  —  POSITION:     Woman,  age  43.     Prone. 

ROENTGEN  CONCLUSIONS:     Pathological  gall-bladder. 

OPERATIVE  FINDINGS:     Gall-bladder  distended,  thickened  and  full  of  very  small  crystals. 

A     Increased  density  in  the  region  of  the  gall-bladder  which  is  constant  throughout  a  series  of  plates. 


Figure  214 

PATIENT  — POSITION:     Woman,  age  6L     Prone. 

ROENTGEN  CONCLUSIONS:     Large  number  of  small  gall-stones. 

OPERATIVE  FINDINGS:     Twelve  gall-stones  the  size  of  beans  removed  from  the  gall-bladder. 

A — B     Group  of  gall-stones  which  show  faint  peripheral  shadows. 


Figure  215 

PATIENT  — POSITION:     Man,  age  58.     Prone. 
ROENTGEN  CONCLUSIONS:     A  large  number  of  gall-stones. 
OPERATIVE  FINDINGS:     Over  two  thousand  gall-stones  found. 

A    The  upper  limits  of  the  gall-bladder. 

B    Thirteen  of  the  gall-stones. 

Arrows  point  to  outline  of  gall-stones.     Patient  weighed  190  pounds. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


163 


FIGURE  212 


FIGURE  213 


FIGURE  214 


FIGURE  215 


164  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  216 

PATIENT  — POSITION:     Woman,  age  40.     Prone. 

ROENTGEN  CONCLUSIONS:     Adhesions  holding  the  stomach  to  the  subhepatic  region  due  to  gall-bladder 
involvement. 

OPERATIVE  FINDINGS:     Extensive  adhesions  from  the  liver  and   gall-bladder  to  the  duodenum   and 
stomach.     Pathological  gall-bladder. 

A — B    Pressure  of  gall-bladder  on  the  duodenum. 


Figure  217 

Same  case,  upright  position,  showang  fixation  of  the  stomach  to  the  subhepatic  region. 

A    Antrimi  of  stomach. 

B    First  portion  of  duodeniun. 

C    Edge  of  liver. 


Figure  218 

PATIENT  — POSITION:     Man,  age  52.     Prone 
ROENTGEN  CONCLUSIONS:     Two  large  dense  gall-stones. 
OPERATIVE  FINDINGS:     No  operation. 

A — B    Outline  of  two  gall-stones. 


Figure  219 

PATIENT  — POSITION:     Man,  age  56.     Prone. 

ROENTGEN  CONCLUSIONS:     Three  gall-stones. 

OPERATIVE  FINDINGS:     Operated  upon  for  other  conditions,  but  gall-stones  not  removed. 

A    Three  gall-stones. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


165 


FIGURE    216 


FIGURE    217 


FIGURE  218 


FIGURE  219 


166  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


SECTION   VI 


THE  SMALL  INTESTINE 

Jejunum  —  Ileum  —  Normal    Roentgen    Picture  —  Malposition  — 
Functional    and    Organic    Disturbances 

In  the  study  of  the  small  intestine  our  attention  is  given  to  the  diseases  of  the  jeju- 
num and  ileum.  The  first  portion  of  the  duodenum,  functionally  and  anatomically,  is  so 
closely  related  to  the  stomach  that,  for  convenience,  we  have  considered  it  a  part  of  the 
stomach  rather  than  a  part  of  the  small  intestine. 

The  passage  of  the  bismuth  through  the  normal  small  intestine  is  rapid.  The  speed 
depends  upon  the  degree  of  intestinal  activity.  Frequently,  within  fifteen  minutes  after 
the  bismuth  meal,  bismuth  is  seen  in  the  caecum.  On  the  other  hand,  at  the  end  of  four 
hours  we  have  seen  all  the  food  still  in  the  small  intestine.  There  is  almost  continual  mo- 
tion among  the  intestinal  coils,  so  that  our  exposure  must  be  less  than  half  a  second  to 
obviate  blurring. 

Throughout  the  jejunum  we  find  the  bismuth  in  finely  divided  particles  producing  a 
feathery  or  lacehke  appearance.  In  a  general  way  we  can  recognize  the  coils  of  intestine, 
but  no  information  concerning  the  finer  structure  of  the  fining  membrane  can  be  learned. 
In  the  second  and  third  portions  of  the  duodenum,  however,  we  are  usually  able  to 
distinguish  the  individual  valvulse. 

In  the  ileum  we  find  the  bismuth  particles  collecting  together  into  small,  discrete 
masses.  In  the  terminal  ileum,  unless  the  emptying  is  too  rapid,  we  find  the  coils  com- 
pletely filled  with  a  homogeneous  dense  bismuth  mass. 

The  important  problems  which  one  encounters  in  the  study  of  the  small  bowel  are 
first,  malposition,  which  may  be  congenital  or  acquired;  second,  functional  diseases;  third, 
organic  disease,  which  includes  ulcer,  new  growth  and  adhesions. 

The  small  intestine  may  be  subject  to  ptosis  when  a  general  visceroptosis  is  present. 
This  condition  is  not  common  and  has  no  particular  clinical  significance.  The  Roentgen 
plate  simply  shows  coils  of  ileimi  low  down  in  the  pelvis. 

Occasionally  in  hernial  sacks,  inguinal,  umbilical  or  post-operative  coils  of  intestine 
can  be  detected.  This  has  some  diagnostic  value  where  surgical  treatment  is  being  con- 
sidered. 

Valuable  evidence  is  given  us  in  the  characteristic  displacement  of  the  small  intestine 
by  intra-abdominal  tumors.  Enlarged  spleen,  hj^pernephroma  and  other  kidney  enlarge- 
ments, aneurism  of  the  aorta,  and  tumors  of  the  pelvic  organs  are  some  common  causes 
of  displacement.  Pregnancy,  with  the  enlargement  of  the  uterus,  and  sometimes  a  dilated 
bladder  in  diabetic  or  prostatic  cases  will  be  easilj^  visualized.  Large  masses  of  mesenteric 
glands  may  displace  various  portions  of  the  bowel.  Functional  disturbances  of  the  small 
intestine  show  no  characteristic  Roentgen  picture. 

The  terminal  ileum  has  been  a  great  field  for  study  during  the  past  few  years.  One 
cannot  be  interested  in  this  part  of  the  alimentary  tract  without  studjdng  the  results  of  the 
investigations  of  Lane,  Jordan,  Case,  Bambridge  and  others. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS  167 

In  considering  the  problems  in  this  region,  our  opinions  are  based  on  our  own  actual 
experience.  It  is  possible  that  we  are  more  conservative  in  our  opinions  than  is  warranted 
by  the  progress  made  by  others. 

In  well-nourished  individuals  the  ileum  will  be  well  emptied  in  six  to  eight  hours.  On 
the  other  hand,  poorly  nourished  persons,  past  middle  age,  show  a  certain  amount  of  ptosis 
and  invariably  stasis  in  the  ileum.  We  believe  this  is  physiological  and  in  most  cases  not 
pathological. 

It  has  been  frequently  found  that  in  the  six-hour  examination  there  may  be  a 
marked  accumulation  of  bismuth  in  the  ileum,  with  the  colon  entirely  empty.  This  accumu- 
lation of  ileal  contents  without  evidence  of  any  discharge  through  the  ileocsecal  valve  is 
more  suggestive  of  pathology  in  the  small  bowel  than  the  picture  of  one  loop  that  shows 
the  so-called  "Lane's  kink." 

To  be  safely  classified  as  stasis,  bismuth  should  be  present  in  the  ileum  from  fifteen  to 
twenty-four  hours  or  more.  In  the  presence  of  such  a  marked  ileal  stasis  alone,  we  still 
cannot  safely  make  a  diagnosis  of  mechanical  obstruction  about  the  terminal  ileum.  The 
writers  have  found  marked  ileal  stasis  in  a  number  of  cases  in  which,  at  operation,  no 
demonstrable  lesion  was  found. 

At  times  we  can  show  the  terminal  ileum  kinked  and  adherent  and  associated  with  a 
definite  ileal  stasis.  The  fluoroscope  is  of  value  in  demonstrating  the  presence  of  the  ad- 
hesions. We  cannot  advise  surgical  treatment  on  this  Roentgen  picture  alone,  but  only 
when  accompanied  b}^  a  definite  clinical  picture. 

Ulcer  of  the  jejunum  has  rarely  been  diagnosed  by  us  from  the  Roentgen  plate.  How- 
ever, a  series  of  cases  have  been  studied  at  the  Mayo  Clinic  and  Carman  claims  that  a 
definite  percentage  of  these  cases  can  be  diagnosed  by  the  Roentgen  method.  This  in- 
volvement of  the  small  bowel  must  be  rare,  for  in  our  series  of  two  thousand  cases  to  date, 
not  more  than  four  such  ulcers  have  been  demonstrated.  These  ulcers  occur  usually  after 
gastroenterostomies . 

The  Roengten  evidence  of  new  growth  is  to  be  had  only  in  the  presence  of  obstruction. 
This  obstruction  must  be  nearly  complete.  The  typical  Roentgen  plate  of  new  growth  of 
the  small  intestine  shows  a  stasis  proximal  to  some  definite  point  in  the  intestine.  This 
is  associated  with  more  or  less  dilatation  of  the  proximal  portion  of  the  intestine.  This 
dilatation  may  be  so  extensive  that  the  shadow  of  the  small  intestine  may  be  confused 
with  that  of  the  colon.  In  such  a  case,  however,  the  differentiation  depends  on  the  char- 
acteristic shadow  cast  by  the  valvulse  of  the  small  intestine. 

Adhesions  by  obstructing  the  lumen  may  give  an  appearance  identical  with  that  of 
new  growth.  From  the  Roentgen  point  of  view  we  know  of  no  sure  way  of  making  a  dif- 
ferentiation. The  fact  that  obstruction  from  adhesions  usually  occurs  in  the  right  lower 
quadrant  is  sometimes  of  value  in  making  a  diagnosis,  especially  where  there  is  a  history 
of  previous  appendix  operation  or  old  pelvic  inflammation. 


168  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


THE  SMALL   INTESTINE 


Figure  220 

PATIENT  — POSITION:     Woman,  age  23.     Prone. 

ROENTGEN  CONCLUSIONS:     Anatomical  variation  of  the  stomach  and  duodenum. 

OPERATIVE  FINDINGS:     General  exploratory.     Negative. 

Key  plate. 

1  Pyloric  region,  showing  in  the  antrum  the  effect  of  pressure  from  the  spine. 

2  Poorly  filled  first  portion  of  the  duodenum. 

3  Variation  in  the  position  of  the  descending  duodenum. 

4  Typical  plate  showing  character  of  the  jejunum. 


Figure  220A 

Key  plate. 

This  plate  shows  the  character  of  the  jejunum  as  differentiated  from  the  ileum. 

A    Jejunum. 

B     Ileum. 


THE  ROENTGEN   DIAGNOSIS  OF  SURGICAL  LESIONS 


169 


FIGURE  220A 


170  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


Figure  221 

PATIENT  — POSITION:     Man,  age  70.     Prone. 

ROENTGEN  CONCLUSIONS:     Dilatation  and  obstruction  of  the  jejunum  due  to  fixation  of  jejunum  in 
appendicial  region,  probably  benign  in  character. 

OPERATIVE  FINDINGS:     Obstruction  of  the  jejunum  by  dense  fibrous  adhesions  in  the  right  lower  quad- 
rant.    Patient  died  of  pulmonary  embolism  four  days  after  operation. 

A     Normal  stomach  in  state  of  spasm.     Duodenum  normal. 

B     Dilated  jejunum. 

C     Jejunum  fixed  and  obstructed  in  the  right  lower  quadrant. 


Figure  222 

PATIENT  — POSITION:     Woman,  age  39.     Prone. 

ROENTGEN  CONCLUSIONS:     Adhesions.     Ileal  stasis. 

OPERATIVE  FINDINGS:     Lane's  kink.     Dilatation  of  the  ileum.     Adhesions  about  the  ascending  colon. 

A     Caecum. 

B     Dilated  ileum. 

C     Dilated  ileum. 


THE  ROEXTGEX  DIAGNOSIS  OF  SURGICAL   LESIONS  171 


FIGURE  221 


FIGURE  222 


172  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  223 

PATIENT  — POSITION:     Woman,  age  23.     Prone.     (Six-hour  plate.) 

ROENTGEN  CONCLUSIONS:     Probable  Lane's  kink. 

OPERATIVE  FINDINGS:     Lane's  kink.     Dilatation  of  terminal  ileum  due  to  Lane's  kink. 

A  Proximal  ileum. 

B  Point  of  Idnking. 

C  Distal  ileum. 

D  Caecum. 

Figure  224 

PATIENT  — POSITION:     Man,  age  41.     Prone.     (Six-hour  plate.) 

ROENTGEN  CONCLUSIONS:     Marked  dilatation  of  ileum  in  left  lower  quadrant  with  obstruction. 

OPERATIVE  FINDINGS:     Marked  dilatation  and  obstruction  of  jejunum  by  a  small  annular  carcinoma. 

A    Arrow  points  to  obstruction  in  jejunum. 
Patient  weighed  280  pounds. 


Figure  225 

PATIENT  —  POSITION:     Man,  age  26.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Twenty-four  hour  ileal  stasis.     Fixation  of  ileum  to  caecum  and  into  pelvis 
by  bands. 

OPERATIVE  FINDINGS:     Chronic  appendix  and  adhesions  with  fixation  of  terminal  ileum. 

A     Site  of  fixation  of  ileum. 


Figure  226 

PATIENT  — POSITION:     Man,  age  19.     Prone.     (Eight-hour  plate.) 
ROENTGEN  CONCLUSIONS:     Fixation  of  terminal  ileum,  Lane's  kink. 
OPERATIVE  FINDINGS:     Lane's  kink.     Chronic  appendix. 

A    Point  of  fixation  of  ileum. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


173 


FIGURE    223 


FIGURE   224 


FIGURE  225 


FIGURE   226 


174  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  227 

PATIENT  —  POSITION:      Man,   age  29.     Prone.      (Ten-hour  plate.) 
ROENTGEN   CONCLUSIONS:     Adhesions  about  ascending  colon  with  Lane's  kink. 
OPERATIVE  FINDINGS:     Lane's  kink.     Chronic  adherent  appendix. 

A     Point  of  fixation  of  ileum. 

B     Effect  of  adhesions  about  ascending  colon. 

C     Coil  of  dilated  ileum. 


Figure  228 

PATIENT  —  POSITION:     Man,  age  26.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Marked  obstruction  of  ileum. 

OPERATIVE  FINDINGS:     Marked  obstruction  of  ileum  due  to  pelvic  band. 

A    Site  of  obstruction  of  ileum. 
B     Coil  of  ileum. 

Figure  229 

PATIENT  —  POSITION:     Man,  age  46.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Marked  obstruction  of  ileum  due  to  general  adhesions  about  caecum. 

OPERATIVE  FINDINGS:     Extensive  adhesions    about   caecum    and   ileum,    apparently   following   an   old 
peritonitis. 

A    Dilated  and  filled  coils  of  ileum. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


175 


FIGURE   227 


FIGURE   228 


FIGURE   229 


176  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  230 

PATIENT  — POSITION:     Girl,  age  16.     Prone. 

ROENTGEN  CONCLUSIONS:     Marked  dilatation  of  terminal  ileum.     Chronic  appendix.     Lung  examina- 
tion; acute  miliary  tuberculosis. 
OPERATIVE  FINDINGS:     Marked  dilatation  of  terminal  ileum  due  to  extensive  tubercular  peritonitis. 

A    Dilated  terminal  ileum. 
B     Chronic  appendix. 

Figure  231 

PATIENT  — POSITION:     Man,  age  41.     Prone.     (Six-hour  plate.) 

ROENTGEN  CONCLUSIONS:     Ileal  stasis. 

OPERATIVE  FINDINGS:     Marked    involvement    in    right  lower    quadrant   by    adhesions  following  per- 
forated appendix. 

A    Marked  dilatation  of  terminal  ileum. 


Figure  232 

Same  case  as  Figure  231,  twenty-four  hours  after  bismuth  meal. 

B     Partly  obliterated  appendix. 

It  is  to  be  noted  that  the  ileum  is  entirely  empty  at  this  time  showing  the  appendix  partly  obliterated. 

It  has  been  the  writers'  experience  that  the  most  marked  obstruction  gave  the  least  stasis. 


THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL  LESIONS 


177 


FIGURE   230 


FIGURE    231 


FIGURE   232 


178  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL  LESIONS 


Figure  233 

PATIENT  —  POSITION:     Man,  age  2L     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Probable  Lane's  kink. 
OPERATIVE  FINDINGS:     Lane's  kink. 

A    Point  of  fixation  of  terminal  ileum  by  pelvic  band. 


Figure  234 

PATIENT  —  POSITION:     Man,  age  49.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Obstruction  of  loop  of  ileum  or  jejunum. 
OPERATIVE  FINDINGS:     Small  annular  carcinoma  of  ileum. 

A    Loop  of  ileum  retaining  bismuth  after  twenty-four  hours. 


THE   ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


179 


FIGURE   233 


FIGURE   234 


180  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL   LESIONS 


Figure  235 

PATIENT  — POSITION:     Woman,  age  35.     Prone. 
ROENTGEN  CONCLUSIONS:     Diverticulum  of  the  jejunum. 
OPERATIVE  FINDINGS:     Diverticulum  not  found. 

See  finding  of  condition  of  lower  bowel  under  Figure  237. 
A     Diverticulum  of  the  jejunum. 


Figure  236 

Same  case  as  Figure  235,  twenty-four  hours  later,  showdng  diverticulum  containing  bismuth  and  air. 
Note  marked  filling  defect  in  caecum. 
A    Filling  defect  in  caecum. 


Figure  237 

Same  case  as  Figures  235  and  236,  by  enema  method,  showing  constant  filhng  defect  in  caecum. 
A    Fining  defect  constant  in  caecum. 

OPERATIVE  FINDINGS:     Extensive  involvement  of  caecum  with  tuberculosis. 


THE  ROENTGEN  DIAGNOSIS   OF   SURGICAL   LESIONS 


181 


FIGURE   235 


FIGURE   236 


FIGURE  237 


182  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  238 

PATIENT — POSITION:     Woman,  age  30.     Prone. 

ROENTGEN  CONCLUSIONS:     Probable  diverticulum  of  jejunum. 

OPERATIVE   FINDINGS:     No  operation. 

A     From  the  Roentgen  plate  one  would  suppose  that  this  diverticulum  was  bismuth  in  the  ampulla  of 
Vater  but  Roentgenoscopy  proved  this  diverticulum  to  be  part  of  the  jejunum. 


Figure  239 

PATIENT  —  POSITION:     Man,  age  31.     Prone. 

ROENTGEN  CONCLUSIONS:     Marked  twenty-four  hour  ileal  stasis. 

OPERATIVE  FINDINGS:     Extensive  adhesions  about  appendix  involving  transverse  colon. 

A     Marked  ileal  stasis:   bismuth  remaining  in  ileum  from  twenty  to  thirty-six  hours. 


Figure  240 

PATIENT  —  POSITION:     Man,  age  35.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Terminal  ileum  fixed  probably  to  old  appendix  scar. 
OPERATIVE  FINDINGS:     Fixation  of  terminal  ileum  to  old  scar. 

A     Loop  of  ileum  fixed  and  adherent. 


Figure  241 

PATIENT  —  POSITION:     Man,  age  21.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Ileal  stasis  of  twenty-four  hours. 
OPERATIVE  FINDINGS:     Adhesions  about  ileum. 

A     Coils  of  ileum. 


THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


183 


FIGURE   238 


FIGURE   240 


FIGURE   239 


FIGURE  241 


184  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  242 

PATIENT  —  POSITION:     Woman,   age  41.     Prone.      (Twenty-four  hour  plate.) 
ROENTGEN   CONCLUSIONS:     Ileal  stasis  and  pericolic  membrane. 
OPERATIVE  FINDINGS:     Extensive  membrane  formation  and  chronic  appendix. 


A     Ileum. 

B     Fixed  transverse  colon. 


Figure  243 

PATIENT  — POSITION:     Man,   age   29.     Prone.      (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Slight  ileal  stasis  of  twenty-four  hours,  cause  not  determined. 

OPERATIVE  FINDINGS:     Tuberculosis  of  caecum. 


A     Portion  of  caecum  found  at  operation  to  be  tubercular. 


Figure  244 

PATIENT  — POSITION:     Man,   age  33.     Prone.      (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Marked  dilatation  of  terminal  ileum. 
OPERATIVE  FINDINGS:     Lane's  kink  and  adhesions. 

A     Loops  of  dilated  ileum. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


185 


FIGURE   242 


FIGURE   243 


FIGURE  244 


186  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL    LESIONS 


Figure  245 

PATIENT  —  POSITION:     Woman,  age  27.     Prone.     (Six-hour  plate.) 
ROENTGEN  CONCLUSIONS:     Fixation  of  ileum  and  caecum  into  pelvic  cavity. 
OPERATIVE  FINDINGS:     Extensive  adhesions  from  pelvic  organs. 

A    Dilated  ileum. 
B     Csecum. 

Figure  246 

PATIENT  — POSITION:     Man,  age  50.     Prone. 

ROENTGEN  CONCLUSIONS:     Displacement  of  terminal  ileum  to  left  of  median  line  by  dilated  urinary 
bladder,  due  to  tabes  dorsalis. 

OPERATIVE  FINDINGS:     No  operation. 

A     Ileum  displaced  to  left  of  median  line. 


Figure  247 

PATIENT  — POSITION:     Woman,  age  35.     Prone. 

ROENTGEN  CONCLUSIONS:     Displacement  of  ileum  by  a  gravid  uterus. 

OPERATIVE  FINDINGS:     No  operation. 

Note:  This  plate  demonstrates  clearly  the  Roentgen  appearance  of  jejunum  and  ileum. 

A     Jejunum. 

B     Ileum. 

C — D     Space  occupied  by  u  terus. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


187 


FIGURE   245 


FIGURE   246 


FIGURE  247 


188  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


SECTION  VII 

APPENDIX 

Meals  —  Technique  —  Pathological  Appendices 

The  Roentgen  investigation  of  the  appendix  has  been  distinctly  an  American  con- 
tribution. The  faulty  technique  of  the  Continental  school  is  acknowledged  by  European 
Roentgenologists.  Schwartz,  for  his  work  on  the  gastro-intestinal  tract,  sent  to  Case  for  the 
use  of  several  plates  showing  appendices.  Their  fundamental  difficulty  seems  to  lie  in  the 
character  of  the  opaque  meal.  (The  cereal  mixtures,  for  one  reason  or  another,  do  not 
readily  enter  the  appendix.)  We  claim  with  our  meal  of  buttermilk  and  barium  that,  in 
every  instance,  unless  the  lumen  has  been  obliterated,  the  appendix  will  fill  and  it  will 
remain  so  long  enough  to  be  demonstrated  on  the  Roentgen  plate  or  Roentgenoscope.  To 
this  statement  we  believe  there  is  no  exception. 

TECHNIQUE 

The  technique  is  comparatively  simple.  The  character  of  the  opaque  meal  is  the  all- 
important  factor.  Ninety  grammes  of  bismuth,  or  equivalent  of  barium,  in  a  pint  of  butter- 
milk is  the  meal  which  will  allow  the  appendix  to  be  satisfactorily  visuahzed.  In  a  hospi- 
tal where  a  malted  milk  meal  is  used,  the  technique  otherwise  being  identical  with  ours, 
out  of  three  hundred  routine  bismuth  examinations,  the  appendix  was  visualized  in  less 
than  thirty.  We  are  ignorant  of  the  reason  for  this.  It  has  been  suggested  that  the  fer- 
mented milk  reaches  the  caecum  in  a  more  fluid  state  than  the  other  media.  Then  again 
its  acid  reaction,  or  possibly  even  the  presence  of  the  lactic  acid  bacilli,  may  have  some 
bearing  on  the  matter.  Whatever  the  mechanical  or  physiological  reason,  we  know  em- 
pirically from  our  experience  covering  four  years  that  the  buttermilk  meal  is  of  funda- 
mental importance  for  visualizing  the  appendix.  The  bismuth  enema  is  of  no  great  value 
in  demonstrating  the  appendix.  We  have  only  occasionally  seen  the  lumen  of  the  appendix 
filled  by  the  enema  method. 

Secondly,  let  us  call  attention  to  the  necessity  of  careful  plate  work.  The  Roentgeno- 
scope, to  be  sure,  has  a  place  in  the  study  of  the  apperidix.  But,  as  a  matter  of  fact,  the 
appendix  shadow  in  not  a  few  cases  is  threadhke  and  oftentimes  but  a  series  of  three  or 
four  dots,  so  that  its  study  becomes  a  matter  of  fine  detail.  For  the  visualization  of  detail, 
plates  are  essential. 

Case  first  emphasized  the  importance  of  the  patient's  position  in  his  work,  laying  great 
stress  on  the  advantage  of  the  horizontal  position.  We,  also,  have  found  this  position  the 
most  suitable.  Plates  are  made  both  from  the  front  and  back.  The  upright  position  may 
occasionally    bring   the   appendix   to   view  when   others   fail.     In   a   few   cases   a    retrocsecal 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS  189 

appendix  may  be  shown  by  means  of  what  we  call  the  lateral  obhque  view.  In  this  posi- 
tion the  posterior  surface  of  the  caecum  is  shown  in  profile.  The  patient  lies  with  his  right 
side  on  the  plate.  He  then  rotates  on  a  longitudinal  axis,  so  that  the  plane  of  the  ab- 
dominal wall  forms  an  angle  of  about  sixtj^-seven  degrees  with  the  plate.  The  tube  is  per- 
pendicular to  the  plate  and  centered  over  the  caecum.  A  retrocsecal  appendix  may  also 
be  shown  by  waiting  until  the  caecum  is  partialh'  evacuated,  twenty-four  to  thirty-six  hours 
after  the  meal,  when  the  appendix  can  be  seen  through  the  shadow  of  the  caecum.  If  one 
fails  to  locate  the  appendix  thus,  the  screen  may  be  of  aid.  jXIanipulation  may  be  neces- 
sary to  bring  the  appendix  to  view  if  hidden  behind  the  caecum  or  coils  of  ileum.  These 
can  be  held  or  pushed  to  one  side  with  gloved  hand  or  "wooden  spoon."  Once  having 
located  the  appendix,  then  plates  can  be  made.  The  screen,  associated  with  palpation, 
furthermore  can  give  evidence  of  appendicial  adhesions  and  the  possible  relation  of  any 
tender-point  to  the  appendix. 

The  six  and  twenty-four  hour  plates  are  the  ones  most  hkely  to  show  the  appendix. 
The  appendix  probably  begins  to  fill  shortly  after  the  meal  enters  the  caecum.  However, 
the  twentj^-four  hour  plate  usually  shows  the  appendix  best,  for  in  the  earher  plate  coils 
of  bismuth-filled  ileum  tend  to  cover  it  over.  Later  plates  will  be  made  if  it  be  important 
to  determine  the  length  of  time  which  the  appendix  retains  the  opaque  salt. 


PATHOLOGICAL  APPENDICES 

In  order  to  recognize  the  pathological  appendix  we  must  first  familiarize  ourselves  with 
its  normal  appearance.  The  appendix  is  made  visible  by  the  meal  in  its  lumen  or  by  fecal 
concretions  which  it  may  contain.  The  concretions  may  be  mistaken  for  calculi  in  the 
iireter.  The  filled  appendix  appears  on  the  Roentgenogram  as  a  hnear  shadow  apparently 
projecting  from  the  inner  edge  of  the  caecum.  The  distal  end  floats  free  in  the  abdominal 
cavity.  It  may  he  verticaUy  behind  the  caecum,  or  horizontally  along  the  pehdc  brim, 
or  hang  over  the  pelvic  brim  into  the  pelvis.  It  may  be  high  in  the  abdominal  cavity, 
even  above  the  ihac  crest,  or  low  in  the  pelvis,  depending  on  the  position  of  the  caecum. 
It  is  freely  movable  under  palpation.  It  varies  in  length  from  an  inch  or  less,  up  to  eight 
or  nine  inches.  Its  width  ranges  from  a  quarter  of  an  inch  to  the  diameter  of  a  thread. 
It  maj"  be  perfectly  straight,  curved,  or  obtusely  angulated. 

The  appendix  usually  shows  as  a  dense  homogeneous  shadow.  It  may  frequently  appear 
segmented  as  a  series  of  dots  or  dashes.  This  appearance  may  be  produced  by  contrac- 
tions of  circular  muscle  fibres  in  the  appendix  wall. 

It  is  to  be  remembered  that  the  normal  appendix  may  intermittently  fill  and  empty. 
When  the  first  plate  is  made  the  appendix  may  be  empty,  but  another  plate  made  five 
minutes  later  will  find  it  fuU.  This  is  particularly  true  in  children.  The  writers  have 
in  mind  a  child  of  three  years  where  this  condition  showed  to  a  marked  degree.  The  normal 
appendix  does  not  retain  barium  or  bismuth  for  any  longer  time  than  does  the  caecum. 

One  source  of  error  is  to  confuse  a  small  residue  in  the  terminal  ileum  for  the  appendix 
shadow. 

The  pathological  appendix  may  be  acute  or  chronic.  In  acute  appendicitis,  the  Roentgen 
ray  is  of  httle  diagnostic  value  and  fortunately  the  clinical  picture  is  usually  definite  enough. 
In  some  cases  of  acute,  left-sided  pain,  transposed  viscera  may  be  shown  by  an  opaque 
enema,  or  if  there  is  time,  the  appendix  itself  can  be  shown  by  the  usual  meal. 


190  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 

Chronic  appendicitis  may  be  shown  by: 

1.  Absence  of  the  appendix  shadow. 

2.  Abnormal  conditions  of  position,  shape,  and  size  of  the  lumen. 

3.  Concretions. 

4.  Tender-point. 

5.  Adhesions. 

To  repeat,  every  normal  appendix  will  show  on  the  plate.  Without  history  of  appendec- 
tomy, an  absence  of  the  appendix  shadow  means  either  that  its  lumen  has  at  least  been 
partially  obhterated  by  old  inflammation,  or  is  obstructed  by  a  possible  kink,  or  it  may 
be  so  filled  with  mucus  or  concretions  that  the  bismuth  cannot  enter.  It  is  conceivable 
that  an  acute  inflammation  could  so  congest  the  walls  that  the  lumen  would  be  obhterated. 
In  any  case  the  appendix  is  pathological.  This  is  all  the  more  certain  if,  with  the  Roent- 
genoscope,  tenderness  is  elicited  over  the  appendix  area. 

A  retrocsecal  appendix  should  be  regarded  with  suspicion.  However,  we  beheve  that 
a  normal  appendix  may  occupy  this  position,  but  it  will  be  freely  movable.  A  retrocsecal 
appendix  that  is  fixed  is  nine  times  out  of  ten  pathological. 

The  size  of  the  appendix,  we  have  found,  is  of  no  special  pathological  significance. 
Very  rarely  dilatation  can  be  demonstrated,  either  of  the  whole  appendix  or  of  the  tip. 
This  means  at  some  point  there  is  obstruction  which  prevents  emptying.  This  condition 
is  more  or  less  characteristic  of  acute  appendicitis. 

Variations  in  shape  may  be  caused  by  concretions,  kinks  and  adhesions.  Some  of  the 
curves  seen  at  times  give  almost  the  appearance  of  knots.  All  these  conditions  we  consider 
abnormal. 

The  presence  of  concretions  is  certainly  pathological.  Concretions,  because  of  their 
density,  may  show  independently  of  the  opaque  meal.  They  may  be  mistaken  for  calcified 
tubercular  glands,  phlebohths  or  uretal  calculi.  In  the  filled  appendix  they  cause  definite 
defects.    They  appear  as  small  circular  vacuoles  within  the  appendix  shadow. 

Palpation  with  the  Roentgenoscope  may  reveal  tenderness  over  the  appendix.  When 
found,  this  phenomenon  is  quite  pathognomonic  of  appendicitis.  The  writers  remember 
one  case  where  pressure  on  the  tip  of  the  appendix  caused  exquisite  pain.  The  patient  was 
operated  upon  the  following  day.  The  end  of  the  appendix  was  dilated,  filled  with  pus, 
and  about  ready  to  rupture. 

Stasis  in  the  appendix  at  least  suggests  possible  future  trouble.  One  frequently  sees 
bismuth  retained  in  the  appendix  a  week  after  the  whole  colon  has  been  emptied.  Case 
reports  a  case  where  the  appendix  still  retained  bismuth  on  the  twentieth  day.  Pirie  men- 
tions a  case  where  the  bismuth  was  present  on  the  forty-third  day.  This  condition  of  stasis 
means  that  the  appendix  drains  itself  poorly.  This  is  a  fertile  field  for  the  formation  of 
fecaliths  with  sooner  or  later  a  definite  appendicitis. 

Evidence  of  adhesions  may  be  shown  by  the  Roentgenoscope  or  by  serial  plates  made 
with  the  patient  in  several  positions.  Adhesions  involving  the  appendix  itself  tend  to  hold 
it  fixed  in  a  position.  The  demonstration  of  a  permanent  fixation  between  the  appendix 
and  some  other  organ  or  the  abdominal  wall  is  of  pathological  significance.  Such  a  con- 
dition is  best  shown  by  palpation  under  the  screen.  The  appendix  may  be  retrocsecal  and 
adherent  to  the  csecum  or  bound  down  to  the  posterior  wall.  We  have  seen  the  tip  of 
the  appendix  adherent  to  the  gall-bladder  and,  on  one  occasion,  adherent  to  a  mass  of 
adhesions  about  a  duodenal  ulcer.  The  appendix  may  be  fixed  about  a  loop  of  terminal 
ileum  or  even  to  a  portion  of  a  redundant  sigmoid.  Occasionally  the  appendix  will  be  held 
in  the  pelvis  by  pelvic  inflammation. 


THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS  191 

Adhesions  may  deform  the  appendix  itself,  as  will  be  shown  by  a  condition  of  per- 
manent kinking.    Frequently  a  kink  will  show  better  with  the  patient  in  the  upright  position. 

Adhesions  about  the  csecum,  ascending  colon,  and  ileum,  which  probably  bear  a  casual 
relation  to  appendicitis,  are  discussed  in  their  respective  chapters. 


192  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


APPENDIX 

Figure  248 

PATIENT  — POSITION:     Man,  age  32.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Normal  large  bowel. 

OPERATIVE  FINDINGS:     One  year  after  Roentgen  examination  for  acute  appendicitis. 

Key  plate. 

1  Caecum. 

2  Ascending  colon. 

3  Hepatic  flexure. 

4  Transverse  colon. 

5  Splenic  flexure.- 

6  Descending  colon. 

7  Sigmoid. 

8  Rectum. 

9  Appendix 

This  plate,  with  the  exception  of  the  condition  of  the  appendix,  is  as  like  the  classical  text-book  type  as  one 
will  find  in  the  average  normal  adult  Roentgenographically. 


Figure  249 

PATIENT  — POSITION:     Woman,  age  22.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Chronic  obliterative  appendix. 

OPERATIVE  FINDINGS:     Chronic  appendix  with  obliteration  of  the  distal  portion. 

A  Appendix.     (Note  the  tapering  of  the  visible  distal  portion.) 

B  Caecum. 

C  Transverse  colon. 

D  Splenic  flexure. 

E  Apparent  fixation  of  the  distal  portion  of  the  transverse  colon. 

F  Redundant  sigmoid. 


THE  ROEXTGEX  DIAGNOSIS   OF  SURGICAL  LESIONS 


193 


194  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  250 


PATIENT —  POSITION:  Woman,  age  28.  Prone. 
ROENTGEN  CONCLUSIONS:  Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A    Caecum. 

B     Kinked  appendix. 


Figure  251 

PATIENT  —  POSITION:  Woman,  age  28.  Prone. 
ROENTGEN  CONCLUSIONS:  Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix  with  several  concretions. 

A     Ileal  stasis. 

B     Appendix  with  four  concretions. 


THE   ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


195 


FIGURE  251 


196  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  252 


PATIENT  — POSITION:  Woman,  age  43.  Prone. 
ROENTGEN  CONCLUSIONS:  Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A     Caecum. 

B— C     Kinks. 

D     Obliteration  of  distal  half  of  the  appendix. 

E    Marker  (tender-point). 


Figure  253 

PATIENT  — POSITION:     Woman,  age  30.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  appendix  with  adhesions  about  the  hepatic  flexure. 

OPERATIVE  FINDINGS:     Pericolic  membrane.     Chronic  appendix. 

A     Appendix  with  three  concretions. 

B     Csecum. 

C     Point  of  fixation  of  proximal  transverse  colon  to  ascending  colon. 


Figure  254 

PATIENT  —  POSITION:     Man,  age  39.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A     Caecum. 

B     Chronic  appendix. 


THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


197 


FIGURE   252 


FIGURE   253 


FIGURE   254 


198  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  255 

PATIENT  — POSITION:     Man,  age  43.     Prone.     (Six-hour  plate.) 
ROENTGEN  CONCLUSIONS:     Fixed  and  retroceecal  chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A    Retrocseca]  appendix. 

B     Distal  portion  of  appendix. 


Figure  256 

Same  case  as  Figure  255. 

This  plate  was  taken  twentj'-four  hours  after  the  bismuth  meal. 

Note  the  empty  bowel,  but  bismuth  still  retained  in  the  appendix. 

A    Appendix. 


Figure  257 

PATIENT  — POSITION:     Man,  age  36.     Prone.     (Six-hour  plate.) 

ROENTGEN  CONCLUSIONS:     Chronic  appendix. 

OPERATIVE  FINDINGS:     Chronic  appendix.     Distal  half  obliterated. 

A     Note  the  kinking  and  obliteration  of  the  distal  portion  of  the  appendix. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


199 


FIGURK   255 


FIGURE   256 


FIGURE   257 


200  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  258 

PATIENT  —  POSITION:     Man,  age  19.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix. 
OPERATIVE  FINDINGS:     Kinked  appendix. 

A     Kinked  appendix. 
B     Empty  caecum. 


Figure  259 

PATIENT  —  POSITION:     Man,  age  38.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Kinked  and  retrocsecal  appendix  with  concretions. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A    Appendix. 


Figure  260 

PATIENT  —  POSITION:     Man,  age  23.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix.     PericoHc  membrane. 
OPERATIVE  FINDINGS:     Chronic  appendix.     Adhesions  about  the  ascending  colon. 

A     Chronic  appendix. 

B     Narrowing  of  bowel  which  was  not  as  marked  when  only  partly  filled. 

The  dilatation  of  the  cajcum  depends  upon  the  amount  of  food  passing. 


THE  ROENTCxEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


201 


FIGURE   258 


FIGURE   259 


202  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  261 

PATIENT  —  POSITION:  Man,  age  29.  Prone.  (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:  Chronic  appendix,  retrocaecal  and  adherent. 
OPERATIVE  FINDINGS:     Adherent  and  retrocecal  appendix. 


A     Proximal  portion  of  the  appendix. 
B     Distal  portion  of  the  appendix. 


Figure  262 

PATIENT  —  POSITION:     Girl,  age  13.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Kinked  appendix. 

OPERATIVE  FINDINGS:     Appendix  fixed  and  kinked  in  mid  portion. 

A     Note  that  the  bismuth  is  precipitated  distally  and  proximally  from  the  mid  portion. 


Figure  263 

PATIENT  — POSITION:     Man,  age  23.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix,  obliterative  type. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A     Chronic  appendix. 


THE   ROEXTGEX   DIAGNOSIS   OF  SURGICAL  LESIOXS 


203 


FIGURE    261 


FIGURE    262 


FIGURE  263 


204  THE   ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


Figure  264 

PATIENT  —  POSITION:     Woman,  age  40.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Fixation  of  appendix  and  cscum  to  left  of  the  median  line. 
OPERATIVE  FINDINGS:     Chronic  appendix  found  beneath  umbilicus. 

A     Caecum  well  to  left  of  median  line. 
B     Appendix. 


Figure  265 

PATIENT  —  POSITION:     Woman,  age  24.     Prone.     (Twenty- four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A     Kinked  portion  of  the  appendix. 


Figure  266 

PATIENT  — POSITION:     Woman,  age  29.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  appendix,  retrocsecal  and  external. 

OPERATIVE  FINDINGS:     Chronic  appendix. 

A     Cfficum. 
B     Appendix. 


THE   ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


205 


FIGURE  264 


FIGURE  255 


FIGURE   266 


206  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  267 

PATIENT  —  POSITION:     Woman,  age  29.     Prone. 

ROENTGEN  CONCLUSIONS:     Chronic  appendix,  kinked  in  mid  portion. 

OPERATIVE  FINDINGS:     Chronic  appendix. 

A    Appendix. 


Figure  268 

Artist's  drawing  of  Figure  267. 


Figure  269 

PATIENT  —  POSITION:     Woman,  age  33.     Prone.     (Twenty-four    hour  plate.) 

ROENTGEN  CONCLUSIONS:     Chronic  appendix  with  adhesions  about  the  colon. 

OPERATIVE  FINDINGS:     Extensive    adhesions    about    the    ascending    and    transverse    colon.     Chronic 
appendix. 

A    Appendix. 

B     Colon  fixed  into  right  quadrant. 

C     Caecum. 

Figure  270 

PATIENT  —  POSITION:     Man,  age  28.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A     Stenosis  and  kinking  in  mid  portion  of  the  appendix. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


207 


FIGURE   267 


FIGURE   268 


FIGURE   269 


FIGURE  270 


208 


THE   ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


Figure  271 
PATIENT  — POSITION:     Man,  age  26.     Prone.      (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix  markedly  kinked. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A    Appendix,  retrocecal  and  external. 
B     Marked  kinking. 

Figure  272 
PATIENT  —  POSITION:     Man,  age  26.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A     Kinked  appendix. 


Figure  273 
PATIENT  — POSITION:     Man,  age  29.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A     Chronic  kinked  appendix. 


Figure  274 
PATIENT  — POSITION:     Woman,  age  29.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix  adherent  about  caecum. 

A    Note  kinked  and  accidental  outline  of  size  of  the  lumen  of  the  appendix. 
B     Filling  defect  proved  at  operation  to  be  due  to  adhesions. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


209 


FIGURE   271 


FIGURE   272 


FIGURE   273 


FIGURE   274 


210  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  275 

PATIENT  —  POSITION:     Man,  age  26.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix  markedly  kinked. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A    Appendix. 


Figure  276 

PATIENT  —  POSITION:     Man,  age  23.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Chronic  appendix  which  is  kinked.     Probable  Lane's  kink  of  ileum. 

OPERATIVE  FINDINGS:     Lane's  kink.     Adherent  and  kinked  appendix. 

A    Point  of  fixation  of  ileum  by  pelvic  band. 
B    Appendix  adherent  and  fixed. 


Figure  277 

PATIENT  — POSITION:     Woman,  age  30.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A    Note  while  large  bowel  is  practically  free  of  bismuth,  it  is  still  retained  in  the  appendix. 


Figure  278 

PATIENT  —  POSITION:     Woman,  age  23.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Kinked  appendix. 

OPERATIVE  FINDINGS:     Markedly  dilated  lumen  with  several  points  of  fixation  and  kinking  by  adhesions. 

A    Note  size  of  liunen  of  the  appendix. 
B     Distal  point. 


THE  ROEXTGEX  DL4GX0SIS   OF  SURGICAL  LESIONS 


^Yh 


211 


FIGURE   275 


FIGURE   276 


FIGURE   277 


FIGURE   278 


212  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  280 

PATIENT  —  POSITION:     Man,  age  26.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A     Note  irregular  filling  of  the  appendix  and  kinking  at  one  portion. 
B     Distal  portion. 


Figure  281 

PATIENT  — POSITION:     Man,  age  48.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix  fixed  to  gall-bladder  region. 
OPERATIVE  FINDINGS:     Gall-stones.     Chronic  appendix  fixed  to  base  of  gall-bladder. 

A     Proximal  portion  of  appendix. 

Arrow  points  to  appendix  passing  up  and  behind  csecum. 

(See  Figure  202,  Section,  Gall-Bladder.) 


Figure  282 

PATIENT  — POSITION:     Man,  age  40.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A     Appendix. 


THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


213 


FIGURE   280 


FIGURE   281 


FIGURE   282 


214  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  283 

PATIENT  — POSITION:     Man,  age  35.     Prone.     (Six-hour  plate.) 

ROENTGEN  CONCLUSIONS:     Chronic  appendix. 

OPERATIVE  FINDINGS:     Chronic  appendix  confirming  Roentgenogram. 

A    Marked  kinking. 
(See  artist's  drawing.) 

Figure  284 

Artist's  drawing,  same  case  as  Figure  283. 


Figure  285 

PATIENT  — POSITION:     Man,  age  43.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Retrocsecal  appendix. 

OPERATIVE  FINDINGS:     Appendix  retrocsecal  and  fixed  in  subhepatic  region. 

A    Appendix. 


Figure  286 

PATIENT  — POSITION:     Man,  age  36.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Adhesions  and  chronic  appendix  with  concretion. 
OPERATIVE  FINDINGS:     Chronic  appendix  with  adhesions. 

A     Kinked  appendix. 

B     Adhesions  about  ascending  colon. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


215 


^oe^7f£/f  £^./fi^:Cf-£^rt:^e 


FIGURE   283 


FIGURE   284 


FIGURE  285 


FIGURE   286 


216  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  287 

PATIENT  —  POSITION:     Man,  age  39.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Chronic  appendix,  retrocaecal  and  adherent. 

OPERATIVE  FINDINGS:     Four    days    after   examination    an    acute   appendix    developed    which   became 
gangrenous  before  removal. 

A     Proximal  portion. 
B     Distal  portion. 

Figure  288 

PATIENT —  POSITION:     Man,  age  46.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix  with  concretions. 
OPERATIVE  FINDINGS:     Chronic  appendix  with'  several  concretions. 

A     Empty  cxcum. 
B    Appendix. 


Figure  289 

Same  case  as  Figure  288  forty-eight  hours  later,  showing  bismuth  filled  appendix.     One  week  from   this 
examination  patient  was  operated  upon  and  appendix  still  contained  bismuth. 


Figure  290 

PATIENT  —  POSITION:     Man,  age  61.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix  with  concretions. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A     Proximal  portion. 
B     Distal  portion. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


217 


FIGURE  287 


FIGURE   288 


FIGURE   289 


FIGURE  290 


218  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  291 

PATIENT  —  POSITION:     Man,  age  30.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Adhesions  about  ascending  colon,  and  chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A    Appendix. 

Figure  292 

PATIENT  ^POSITION:     Man,  age  53.     Prone.     (Six-hour  plate.) 

ROENTGEN  CONCLUSIONS:     Very  long  appendix  and  kinked  and  fixed  in  mid  portion. 

OPERATIVE  FINDINGS:     See  Figure  293. 


Figure  293 

Same  case  as  Figure  292.      (Twenty-four  hour  plate.) 
OPERATIVE  FINDINGS:     Chronic  appendix  with  adhesions. 


THE  ROEXTGEX  DL\GXOSIS   OF   SURGICAL  LESIONS 


219 


FIGURE   291 


FIGURE  292 


FIGURE   293 


220  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  294 

PATIENT  — POSITION:     Man,  age  42.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN    CONCLUSIONS:     Chronic  appendix,    retrocsecal    and  external  to  caecum.     Ileum  is  abnor- 
mally external  and  fixed,  probably  by  adhesions. 

OPERATIVE    FINDINGS:     Markedly    kinked    appendix.     The    whole    caecum    deformed    by    extensive 
adhesions. 

A     Appendix. 

B     Terminal  ileum. 

C     Caecum. 

Figure  295 

PATIENT  — POSITION:     Boy,  age  9.     Prone.      (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Chronic  appendix. 
OPERATIVE  FINDINGS:     Chronic  appendix. 

A     Appendix. 


THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS  221 


FIGURE    294 


FIGURE   295 


222  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


SECTION   VIII 


LARGE   INTESTINE 

Method    of    Study  —  Opaque    Meal    and    Enema  —  Normal   Appearance  —  Chronic 

Constipation  —  New   Growth  —  Malformation  and   Malposition  — 

Adhesions  —  Colitis 

METHOD  OF  STUDY 

In  the  study  of  the  colon  we  find  the  Roentgen  ray  to  be  of  diagnostic  value  in  the 
following  conditions:  First,  abnormalities  in  motility;  second,  new  growth;  third,  adhesions; 
fourth,  congenital  or  acquired  malformation  or  malposition;  fifth,  colitis;  sixth,  diverticulitis. 

In  the  usual  routine  the  "six-hour"  and  "twenty-four  hour"  plates  give  us  the  best 
visualization  of  the  colon.  In  the  six-hour  plate  we  normally  find  the  head  of  the  bismuth 
column  at  the  splenic  flexure,  while  the  tail  is  at  the  lower  end  of  the  ileum.  In  the  twenty- 
four  hour  plate  the  colon  should  be  fairly  well  emptied,  or  at  least  only  the  transverse  and 
the  descending  colon  filled.    To  these  limits  there  is  a  wide  normal  variation. 

For  the  diagnosis,  particularly  of  new  growth  and  other  organic  colon  diseases,  the 
best  Roentgen  evidence  is  obtained  from  the  enema-filled  colon.  It  may  be  added  that  no 
gastro-intestinal  examination  is  complete  without  the  opaque  enema. 


OPAQUE  MEAL  AND  ENEMA 

Just  a  word  as  to  the  medium  which  we  employ  for  the  enema  and  the  manner  in 
which  it  is  given.  It  has  been  found  that  six  ounces  of  the  "prepared"  barium  sulphate 
in  a  pint  of  buttermilk,  with  the  addition  of  enough  warm  water  to  make  a  quart,  proves 
a  very  satisfactory  medium.  It  is  cheap,  easily  prepared  and  in  no  way  disagreeable  to  the 
patient.  The  patient  lies  on  the  left  side  (unless  a  Roentgenoscopic  examination  is  to  be 
made  at  the  same  time)  and  a  soft  rectal  tube  is  inserted  about  two  inches.  The  mixture  is 
allowed  to  flow  in  by  gravity,  the  container  never  being  more  than  three  feet  above  the 
level  of  the  patient.  The  enema  is  given  very  slowly  and  the  flow  interrupted  frequently. 
This  is  important  for  the  comfort  of  the  patient. 


NORMAL  APPEARANCE 

Let  us  briefly  review  the  normal  appearance  of  the  large  intestine.  The  caecum  is  that 
portion  of  the  colon  into  which  the  ileum  empties  through  the  ileocsecal  valve.  It  is  almost 
surrounded  by  peritoneum  and  is,  therefore,  freely  movable.  It  may  be  found  in  the  pelvis 
or  displaced  upwards. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS  223 

The  ascending  colon  extends  upwards  and  backwards  into  the  ihac  fossa  and  reaches 
nearly  to  the  liver,  where  it  forms  a  more  or  less  acute  angle.  The  hepatic  flexure,  together 
\vith  the  proximal  portion  of  the  transverse  colon,  may  frequently  be  ptosed,  drawn  forwards 
and  downwards.    This  is  a  normal  condition  for  many  people. 

The  transverse  colon  extends  from  the  hepatic  flexure  to  the  splenic  flexure.  It  varies 
greath'  in  position.  Particularly  in  thin  individuals  it  may  hang  as  a  loop  reaching  into 
the  pelvis.  In  this  position  the  distal  portion  may  appear  to  overlie  the  descending  colon. 
The  Roentgenoscope  or  stereoscopic  plates  are  useful  for  differentiation  in  such  a  condition. 
The  close  relation  between  the  transverse  colon  and  the  greater  curvature  of  the  stomach 
should  be  borne  in  mind. 

The  splenic  flexure  is  firmly  held  to  the  diaphragm  by  a  strong  ileocohc  ligament. 
This  flexm-e  normally  occupies  a  position  several  inches  higher  than  the  hepatic  flexure. 

The  descending  colon  extends  from  the  splenic  flexure  to  the  brim  of  the  pelvis.  This 
portion  of  the  colon  is  practical!}^  retroperitoneal  and  is  fixed. 

The  sigmoid  has  a  great  normal  variation  in  size  and  position,  as  it  is  attached  by  a 
mesentery  which  varies  in  length. 

The  rectum  extends  from  the  external  sphincter  to  the  sigTnoid.  It  is  the  most  dis- 
tensible portion  of  the  colon  and  consequently  has  a  great  normal  variation  in  size  and 
shape. 

CHRONIC   CONSTIPATION 

Chronic  constipation  is  a  condition  which  frequently  requires  a  Roentgen  investigation. 
In  the  cases  which  are  not  due  to  some  definite  obstruction  we  find  two  general  classes: 
First,  those  showing  atony  of  the  colon,  where  we  find  the  colon  markedh'  distended,  usualh^ 
filled  with  gas,  and  a  lack  of  any  definite  peristalsis;  the  second  group  presents  a  spastic 
condition  in  the  colon.  Here  we  find  marked  peristaltic  contractions.  The  bismuth  is  seen 
divided  into  small  masses,  by  spasm  of  the  circular  fibres.  This  is  noted  particularly  in  the 
descending  colon. 

Both  groups  may  or  may  not  be  associated  with  ptosis.  Instead  of  the  twenty-four 
hour  plate  showing  the  colon  fairly  weU  emptied,  a  forty-eight  hour  or  even  ninety-six  hour 
examination  may  stiU  show  the  bismuth  in  the  colon. 

NEW  GROWTH 

New  gro'Ri^h  of  the  colon  appears  on  the  plate  as  a  permanent  fiUing  defect  in  the 
colon  shadow.  The  presence  of  a  lesion  may  first  be  suspected  during  the  course  of  the 
opaque  meal  and  it  is  usually  the  twenty-four  hour  plate  which  gives  the  hint.  Here  we 
find  the  bariiun  being  held  at  some  definite  point  in  the  colon.  There  may  be  proximal 
dilatation,  depending  on  the  severity  of  the  lesion.  Along  with  this  stasis  there  may  be  a 
definite  defect  in  the  colon  outline  usuaUj^  of  an  annular  or  funnel  shape. 

It  is  only  in  the  last  stages  where  there  is  obstruction  that  the  bismuth  meal  gives  us 
any  e\adence.  The  early  cases,  without  obstruction,  are  demonstrated  best  with  the  bismuth 
enema. 

Frequentlj'  it  has  been  observed  that  a  growth  will  offer  no  obstruction  to  the  meal, 
but  does  obstruct  the  passage  of  the  enema.  Schwartz  has  explained  this  by  the  theorj- 
that  the  tumor  has  adapted  itself  from  the  earliest  stages  to  the  pressm-e  of  the  stools 
above,  and  that  its  funnel  is  shaped  by  the  natural  direction  of  the  stools.  On  the  other 
hand,  the  enema,  which  approaches  suddenly  from  below,  does  not  find  the  way  prepared 
for  this  abnormal  direction,  and  real  obstruction  is  created.  The  mechanics  is  simply  that 
of  a  valve. 


224  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 

The  filling  defect,  as  has  been  mentioned,  is  usually  of  an  annular  nature.  However,  it 
may  have  an  irregular,  bitten-out  appearance;  this  is  particularly  true  of  new  growth  in  the 
caecum  or  upper  rectum. 

MALFORMATION  AND  MALPOSITION 

The  Roentgenoscope  has  been  found  of  great  value  in  studying  the  colon.  It  is  impor- 
tant to  watch  the  enema  as  it  flows  in.  It  will  be  noted  that  the  whole  colon  fills  with  bis- 
muth within  a  few  minutes.  The  fluid  is  unirritating  and  flows  easily  and  without  hesitation 
clear  to  the  ileocsecal  valve.  In  cases  of  new  growth  there  is  a  characteristic  halting  at  the 
point  of  hindrance.  This  arrest  may  be  complete  or  may  be  overcome  in  a  longer  or  shorter 
time,  according  to  the  degree  of  stenosis.  The  hindrance  to  the  movement  of  the  bismuth 
stream  may  be  out  of  all  proportion  to  the  degree  of  actual  obstruction. 

The  Roentgenoscope  is  valuable,  for  by  it  a  palpable  tumor  may  be  detected  coinciding 
with  the  fiUing  defect.  However,  the  tumor  will  not  be  a  constant  finding,  particularly  if 
we  attempt  to  make  an  early  diagnosis. 

We  must  guard  against  misinterpretation  of  fiUing  defects  in  the  colon  as  seen  on  the 
plate.  Pressure  from  a  normal  spine  may  produce  a  suspicious  appearance  in  the  transverse 
colon.  There  ma^^  be  a  hiatus  in  the  colon  due  to  normal  peristaltic  movement.  One  of  the 
frequent  confusing  appearances  is  due  to  multiple  diverticula.    This  will  be  discussed  later. 

ADHESIONS 

There  is  no  characteristic  picture  of  adhesions.  We  may  have  a  band  constricting  some 
portion  of  the  colon.  This  will  produce  a  filling  defect  with  proximal  stasis  if  the  obstruc- 
tion is  severe  enough.  This  picture  may  simulate  new  growth.  The  history  may  differen- 
tiate. With  adhesions  we  may  find  more  or  less  displacement  of  the  viscera  associated  with 
the  filling  defect.    This  is  not  characteristic  of  the  defects  from  new  growth. 

The  most  frequent  location  for  adhesions  to  occur  is  in  the  hepatic  flexure  area.  Here 
we  commonly  find  the  ascending  colon  and  the  proximal  transverse  colon  adherent,  pro- 
ducing sharp  angulation  of  the  hepatic  fiexure.  This  condition  may  be  accompanied  by 
more  or  less  stasis  in  the  csecum  and  ascending  colon.  The  Roentgenoscope  is  valuable  in 
determining  the  degree  of  fixation.  This  condition  has  been  described  as  the  "double-barrel 
shot-gun"  appearance.  These  adhesions  may  be  secondary  to  old  gall-bladder  trouble,  or 
possibly  a  congenital  condition,  as  a  so-called  "Jackson's  membrane." 

The  appendix  region  is  also  a  favorite  location  for  trouble  from  adhesions.  This  area 
is  described  more  fully  in  another  chapter. 

Post-operative  adhesions  from  pelvic  operations  in  women  will  frequently  displace  or 
distort  the  colon.  The  sigmoid  is  commonly  found  fixed,  sometimes  held  over  to  the  right 
and  actually  overlying  the  appendix.    It  is  sometimes  held  down  in  the  pelvis. 

The  colon  may  be  displaced  by  other  organs.  An  enlarged  spleen  will  displace  the 
splenic  flexure  downwards.  Likewise  an  enlarged  liver  or  even  gall-bladder  will  give  the 
hepatic  flexure  in  a  low  position.  Various  large  tumors,  such  as  hydronephrosis  of  the 
kidney,  ovarian  cysts  or  even  large  fibroids  will  cause  an  abnormal  position  of  the  colon. 

There  are  rare  congenital  conditions  of  the  colon  which  the  Roentgen  ray  may  reveal. 
Transposition  of  the  viscera  is  not  as  uncommon  as  has  been  supposed.  Redundant  sig- 
moid is  sometimes  found.  These  may  be  enormous,  the  coils  of  sigmoid  almost  equaUing  in 
length  the  rest  of  the  colon.  Congenital  dilatation  of  the  colon,  in  infants  called  "  Hirsch- 
brung's  disease,"  shows  a  characteristic  Roentgen  picture. 


THE   ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS  225 

COLITIS 
We  have  noted  in  conditions  of  colitis  that  the  Roentgenogram  presents  a  more  or  less 
characteristic  appearance.    Following  the  passage  of  the  bismuth  meal  the  wall  of  the  colon 
still  appears  to  retain  a  coating  of  bismuth.    It  has  been  supposed  that  mucus  adhering  to 
the  wall  retains  the  bismuth. 


226  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


LARGE   INTESTINE 

ADHESIONS 

Figure  296 
PATIENT  —  POSITION:     Man,  age  50.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Normal. 
OPERATIVE  FINDINGS:     No  operation. 

Key  plate. 

1  Caecum. 

2  Ascending  colon. 

3  Hepatic  flexure. 

4  Transverse  colon. 

5  Splenic  flexure. 

6  Descending  colon. 

7  Sigmoid. 

8  Appendix. 

Figure  297 

PATIENT  — POSITION:     Woman,  age  38.     Prone. 

ROENTGEN  CONCLUSIONS:     Incompetency  of  the  ileocsecal  valve  due  to  adhesions  about  the  ascending 

colon.     These  adhesions  extend  from  the  region  of  the  caecum  to  the  lesser  curvature  of  the  stomach, 

causing  pressure  on  the  duodenum  and  transverse  colon. 
OPERATIVE  FINDINGS:     Exploration  showed  presence  of  a  dilated  duodenum  due  to  adhesions  which 

caused  a  narrowing  of  lumen.     Appendix  drawn  up,  although  not  grossly  pathological,  tied  off  and  removed. 

Many  adhesions  separated  in  the  right  upper  quadrant. 

Bismuth  enema  examination  and  bismuth  meal. 

A — B — C — D — E    Effect  of  pressure  from  adhesions. 

F     Appendix  and  ileum. 

G    Bismuth  in  ileum  clue  to  incompetency  of  the  ileocsecal  valve. 

H    Marked  atony  of  the  transverse  colon. 


THE   RijEXTGEX   DiACxKOSIS   OF  SI-RGICAL   LES 


LESIONS 


228  THE   ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


Figure  298 

PATIENT  ^POSITION:     Woman,  age  38.     Prone.     Enema. 

ROENTGEN  CONCLUSIONS:     Marked   incompetency   of  the   ileocaecal   valve   due   to    adhesions   about 

caecum. 
OPERATIVE  FINDINGS:      Tuberculosis  of  cacum  and  colon. 

A     Point  of  obstruction  in  colon. 

B     Note  apparent  atony  of  the  colon  due  to  infiltration  of  the  whole  bowel. 

C    Bismuth  having  passed  the  ileocffical  valve  progresses  readily  almost  to  the  stomach. 


Figure  299 

PATIENT  —  POSITION:     Woman,  age  33.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Post-operative  adhesions  subsequent  to  an  acute  perforating  appendix. 

OPERATIVE  FINDINGS:     Extensive  adhesions  about  the  hepatic  flexure.     The  coils  of  ileum  were  external 
to  ascending  colon  and  fixed  to  parietal  peritoneum. 

A     Gas  in  small  bowel  due  to  partial  olistruction. 
B     Ascending  colon. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


229 


FIGURE   299 


230  THE  ROENTGEN  DIAGNOSIS   OF   SURGICAL  LESIONS 


Figure  300 

PATIENT  — POSITION:     Woman,  age  38.     Prone.     Enema. 

ROENTGEN  CONCLUSIONS:     Extensive  adhesions  about  caecum  and  ascending  colon. 

OPERATIVE  FINDINGS:     Pericolitis.     Chronic  appendix.     Dilatation  of  the  caecum  due  to  adhesions. 

A     Transverse  colon  fixed  and  adherent  to  ascending  colon. 
B     Point  of  narro^vdng  due  to  adhesions. 
C    Dilated  csecum. 


Figure  301 

PATIENT  — POSITION:     Woman,  age  19.     Prone.     Enema. 

ROENTGEN  CONCLUSIONS:     Pericolic  membrane.     Fixation  of  proximal  transverse  colon  to  ascending 
colon. 

OPERATIVE  FINDINGS:     Pericolic  membrane  and  adhesions. 

A    Cgecuni . 

B     Fixed  point  of  transverse  cclon. 


Figure  302 

Artist's  drawing  of  Case  301. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


231 


FIGURE  300 


FIGURE  301 


FIGURE    303 


232  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  303 

PATIENT  — POSITION:     Man,  age  21.     Prone. 

ROENTGEN  CONCLUSIONS:     Pericolitis  with  membrane. 

OPERATIVE  FINDINGS:     Jackson's  membrane  with  retrocaecal  appendix. 

A     Fixation  of  transverse  colon  into  right  quadrant. 
B     Caecum. 


Figure  304 

PATIENT  —  POSITION:     Woman,  age  40.     Prone.     (Twelve-hour  plate.) 

ROENTGEN    CONCLUSIONS:      Marked    kinking    and    fixation    of   caecum    and    proximal    portion   of   the 
transverse  colon. 

OPERATIVE  FINDINGS:     Roentgen  observations  confirmed. 

A    Fixation  of  colon. 
B     Ileal  stasis. 

Figure  305 

PATIENT  — POSITION:     Woman,  age  43.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Adhesions  and  fixation  of  proximal  portion  of  the  transverse  colon. 

OPERATIVE  FINDINGS:     Extensive  adhesion  and  membrane  about  ascending  and  transverse  colon. 

A     Filling  defect  due  to  adhesions. 
B     Fixation  of  transverse  colon. 


THE   ROEXTGEX   DIAGXOSIS   OF   SURGICAL   LESIONS 


233 


FIGURE  303 


FIGURE  304 


FIGURE   305 


234  THE  ROENTGEN  DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  306 

PATIENT  —  POSITION:     Woman,  age  48.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Extensive  adhesions  about  the  ascending  colon  and  hepatic  flexure.      Gall- 
stones. 
OPERATIVE  FINDINGS:     Adhesions.     Partial  obstruction  of  ascending  colon  due  in  part  to  gall-bladder 
adhesions. 

A — B    Points  of  obstruction  due  to  membrane. 

Figure  307 

PATIENT  —  POSITION:     Woman,  age  47.     Prone.      (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Adhesions  about  ascending  colon  and  deformity  of  caecum  due  to  post- 
operative  adhesions  from  gall-bladder  disease.      Chronic  appendix. 
OPERATIVE  FINDINGS:     Adhesion   from   gall-bladder   causing   partial    obstruction   of   ascending  colon, 
and  chronic  appendix. 

A  Point  of  fixation  of  colon  due  to  membrane  and  adhesions. 

B  Deformity  of  caecum. 

C  Chronic  appendix. 

D  Sigmoid  fixed  to  base  of  CECcum. 

Figure  308 

PATIENT  — POSITION:     Woman,  age  5L     Prone.     Enema. 

ROENTGEN  CONCLUSIONS:     Post-operative  condition  of  the  ascending  colon. 

OPERATIVE  FINDINGS:     Post-operative  condition  of  the  ascending  colon  due  to  adhesions. 

A     Dilated  terminal  ileum. 

B     Showing  deformity  of  ca?cum. 


THE   R(3EXTGEX   DIAGXOSIS   OF   SURGICAL   LESIONS 


235 


FIGURE  306 


FIGURE  307 


FIGURE   308 


236  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  309 

PATIENT  —  POSITION:     Woman,  age  36.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Marked  pericolic  membrane.     Dilatation  of  caecum. 
OPERATIVE  FINDINGS:     Confirmed  Roentgen  plates. 

A    Stenosis  of  ascending  colon. 

B     Dilatation  of  colon  due  to  obstruction  of  ascending  colon. 


Figure  309A 

PATIENT  —  POSITION:     Woman,  age  32.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Adhesions  about  ascending  colon  due  possibly  to  a  membrane. 
OPERATIVE  FINDINGS:     Pericolic  membrane.     Chronic  appendix. 

A     Point  of  narrowing  in  the  bowel  due  to  membrane. 
B     Appendix. 


Figure  310 

PATIENT  —  POSITION:     Woman,  age  42.     Prone.     (Six-hour  plate.) 

ROENTGEN  CONCLUSIONS:     Pericolic  membrane  of  ascending  colon.     Chronic  appendix. 

OPERATIVE  FINDINGS:     Pericolic  membrane.      Chronic  appendix. 

A     Point  of  narrowing  of  bowel. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


237 


FIGURE   309 


FIGURE   309A 


FIGURE  310 


238  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  311 

PATIENT  — POSITION:     Man,  age  36.     Prone.     Enema. 

ROENTGEN  CONCLUSIONS:     Marked  incompetency  of  the  ileocaecal  valve. 

OPERATIVE  FINDINGS:     No  operation. 

A    Csecum  and  ascending  colon. 

B    Bismuth  passing  back  into  ileum. 


Figure  31  lA 

PATIENT  — POSITION:     Man,  age  50.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Adhesions  about  ascending  colon. 

OPERATIVE  FINDINGS:     Adhesions  about  bowel  causing  narrowing  and  partial  obstruction. 

A     Point  of  actual  narrowing  of  bowel. 


Figure  312 

PATIENT  — POSITION:     Boy,  age  4.     Prone. 

ROENTGEN  CONCLUSIONS:     Obstruction  of  transverse  colon.     Cause  not  determined. 

OPERATIVE  FINDINGS:     Obstruction  of  bowel  due  to  abscess  of  liver,  with  subsequent  adhesions  which 
had  completely  invested  the  colon  and  caused  obstruction. 

A — B     Site  of  obstruction. 

Bowel  almost  completely  obstructed  at  this  point. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


239 


FIGURE  311 


FIGURE  311A 


FIGURE  312 


240  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  313 

PATIENT  —  POSITION:     Baby,  age  6  weeks.     Prone. 

ROENTGEN  CONCLUSIONS:     Hirschbrung's  disease  or  congenital  dilatation  of  large  intestine. 

OPERATIVE  FINDINGS:     Autopsy.     Confirmed  Roentgen  observations. 

A — B     Compare  the  size  of  this  bowel  with  that  of  a  child  of  four  years.     (See  Figure  312.) 


Figure  314 

PATIENT  — POSITION:     Man,  age  20.     Prone.     (Six-hour  plate.) 
ROENTGEN  CONCLUSIONS:     Adhesions  about  ascending  colon  and  caecum. 
OPERATIVE  FINDINGS:     Confirmed  Roentgen  examination. 

A    Dilated  and  obstructed  terminal  ileum. 


Figure  315 

Artist's  drawing  of  Case  314. 


THE   ROEXTGEX   DIAGXOSIS   OF   SURGICAL   LESIONS 


241 


FIGURE  313 


FIGURE  314 


FIGURE  315 


242  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  316 

PATIENT  — POSITION:     Woman,   age   23.     Prone.      (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Extensive  adhesions  about  the  csecum. 

OPERATIVE  FINDINGS:     Obstruction  of  ascending  colon  due  to  old  tubercular  peritonitis. 

A     Obstruction  of  ascending  colon. 

B     Shows  only  a  small  amount  of  bismuth  passing  through  bowel. 


Figure  317 

PATIENT  — POSITION:     Girl,   age   14.     Prone. 

ROENTGEN  CONCLUSIONS:     Pericolic  membrane. 

OPERATIVE  FINDINGS:     Pericolic  membrane.      Chronic  appendix. 


A     Point  of  fixation  of  transverse  colon  to  ascending  colon. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


243 


FIGURE   316 


FIGURE  317 


244  THE  ROENTGEN  DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  318 

PATIENT  — POSITION:     Girl,  age  13.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Fixation  of  transverse  colon  to  old  scar. 
OPERATIVE  FINDINGS:     Fixation  of  omentum  to  old  appendix  scar. 

A     Site  of  fixation  of  transverse  colon  into  pelvis.     This  deformity  was  due  to  the  omentum  being  held 
by  the  scar  from  previous  operation. 


Figure  319 

PATIENT  — POSITION:     Man,  age  21.     Prone.     Enema. 

ROENTGEN  CONCLUSIONS:     Extensive  adhesions  in  upper  right  quadrant. 

OPERATIVE  FINDINGS:      Confirmed  Roentgen  observations. 

A     Point  of  fixation  of  transverse  colon  to  stomach  and  subhepatic  region. 


THE   ROEXTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


245 


FIGURE   318 


FIGURE  319 


246  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  320 

PATIENT  — POSITION:     Man,  age  30.     Prone.     Enema. 

ROENTGEN  CONCLUSIONS:     Pericolic  membrane  of  the  ascending  colon. 

OPERATIVE  FINDINGS:     Pericolic  membrane.     Chronic  appendix. 

A    Point  of  fixation. 

Figure  321 

PATIENT  — POSITION:     Man,  age  35.     Prone.     Enema. 

ROENTGEN  CONCLUSIONS:     Adhesions  about  proximal  portion  of  the  transverse  colon. 

OPERATIVE  FINDINGS:     Confirmed  Roentgen  observations. 

A     Narrowing  of  ascending  colon  due  to  a  band  of  adhesions. 


Figure  322 

PATIENT  — POSITION:     Man,  age  38.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Adhesions  about  ascending  and  proximal  portion  of  transverse  colon. 

OPERATIVE  FINDINGS:     Extensive  involvement  of  whole  of  right  lower  quadrant  with  adhesions,  also 
membrane  formations. 

A     Point  of  fixation  of  transverse  colon. 
B     Csecum. 


THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


247 


FIGURE   320 


FIGURE  321 


FIGURE  322 


248  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  323 

PATIENT  — POSITION:     Man,  age  53.     Prone.     Enema. 

ROENTGEN    CONCLUSIONS:     Extensive    adhesions    about    ascending    colon    probably    causing    incom- 
petency of  ileocsecal  valve. 
OPERATIVE  FINDINGS:     Adhesions,  chronic  appendix.     Sigmoid  attached  to  caecum. 

A     Point  of  obstruction  of  ascending  colon. 
B     Coils  of  ileum. 
C     Sigmoid. 

Figure  324 

Same  case  as  Figure  314. 

One  year  after  operation.      Though  symptoms  have  all  been  relieved,  yet  bowel  position  remains  about 

as  in  early  plates. 

A     Ctecum. 

B     Transverse  colon. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


249 


FIGURE   323 


250  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


INTESTINAL  NE\A^  GROWTH 

Figure  325 

Artist's  drawing  of  Case  326.     See  colored  Plate  IV. 

Figure  326 

PATIENT  —  POSITION:      Woman,  age  49.     Prone.      (Six-hour  plate.) 

ROENTGEN  CONCLUSIONS:     Small  intra-intestinal  new  growth  at  base  of  caecum. 

OPERATIVE  FINDINGS:     Small  intra-intestinal  tumor  about  the  size  of  an  egg. 

A     Filling  defect  due  to  growth,  outline  of  tumor. 

This  tumor  was  dem.onstrated  also  without  the  bismuth  meal. 

Arrows  point  to  outline  of  growth. 

Figure  327 

PATIENT  — POSITION:     Man,   age  58.     Prone.      (Six-hour  plate.) 
ROENTGEN  CONCLUSIONS:     Extensive  new  growth  of  the  cscum. 
OPERATIVE  FINDINGS:     Extensive  new  growth  of  caecum. 

A     Plate  shows  dilatation  of  the  ileum  and  involvement  of  csecum. 
B     Extent  of  new  growth  involving  ascending  colon. 


V^^f^-^Jf'tmtto  n 


li^ 


PLATE  IV  — FIGURE  325 

SMALL   INTRA-INTESTINAL   NEW  GROWTH  AT  BASE  OF   CAECUM 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


251 


FIGURE  327 


252  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  328 

PATIENT  — POSITION:     Man,  age  23.     Prone. 
ROENTGEN  CONCLUSIONS:     New  growth  at  hepatic  flexure. 

OPERATIVE   FINDINGS:      Small     intra-intestinal     tumor     at     hepatic     flexure.       Pathological     report, 
adenocarcinoma. 

A    Filling  defect  in  bowel  due  to  tumor  mass. 

B     Terminal  dilatation  of  ileum  due  to  partial  obstruction  in  bowel. 


Figure  329 

PATIENT  — POSITION:     Woman,  age  69.     Prone.     (Six-hour  plate.) 

ROENTGEN  CONCLUSIONS:     Obstruction  of  bowel  at  hepatic  flexure  due  to  probable  new  growth. 
OPERATIVE  FINDINGS:     Small  annular  new  growth  at  hepatic  flexure,  involving  liver  and  gall-bladder. 
Adenocarcinoma. 

A     Obstruction  at  hepatic  flexure  due  to  small  constricting  annular  groM'th. 


Figure  330 

Same  case  as  Figure  329. 

Artist's  drawing  showing  very  small  constricting  new  growth. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


253 


FIGURE   328 


FIGURE  329 


FIGURE  330 


254  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  331 

PATIENT —  POSITION:      Woman,   age  36.     Prone.      (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     New  growth  of  proximal  portion  of  transverse  colon   causing   complete 
obstruction. 

OPERATIVE  FINDINGS:     Small  annular  new  growth  causing  more  or  less  obstruction. 

A     Point  of  obstruction  sho-n-ing  how  small  an  amount  of  bismuth  is  passing  through  the  towel  at  this  point. 

B    Distended  bowel  due  to  obstruction. 

Note  the  dilatation  of  the  terminal  loops  of  ileum  and  ca?cum,  due  to  the  obstruction  of  the  transverse 

colon. 


Figure  332 

PATIENT  — POSITION:     Man,   age  38.     Prone. 

ROENTGEN  CONCLUSIONS:     A  large  intra-intestinal   new   growth   at  distal  portion  of  the  transverse 
colon. 

OPERATIVE  FINDINGS:     Large  inoperable  new  growth  of  bowel. 

A     Plate  shows  extent  of  the  intra-intestinal  growth. 
Note  the  size  of  the  lumen  of  the  bowel. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


255 


FIGURE  331 


FIGURK  332 


256  THE   ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  333 

PATIENT  — POSITION:     Man,  age  34.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Intra-intestinal  new  growth  at  splenic  flexure. 
OPERATIVE  FINDINGS:     Inoperable  intra-intestinal  new  growth. 

A     Extent  of  new  growth  in  bowel. 

This  filling  defect  was  constant  in  the  six,  twenty-four  and  forty-eight  hour  plates. 

B     Splenic  flexure. 


Figure  334 

Same  case  as  Figure  333. 

Plates  made  forty-eight  hours  later  with  a  bismuth  enema. 

Note  the  fiUing  defect. 


THE  ROENTGEN  DIACxNOSIS   OF  SURGICAL   LESIONS 


257 


FIGURE   333 


FIGURE  33.1 


258  THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  335 

PATIENT  — POSITION:     Man,  age  48.     Prone.     Enema  method. 

ROENTGEN  CONCLUSIONS:     Intra-intestinal  tumor  at  splenic  flexure.     Probable  new  growth. 

OPERATIVE  FINDINGS:     Autopsy.     Extensive  involvement  of  the  transverse  colon.     Adenocarcinoma. 

A  Complete  obstruction  of  the  distal  portion  of  the  transverse  colon. 

B  Splenic  flexin-e. 

C  Descending  colon. 

D  Sigmoid. 

Figure  336 

PATIENT  — POSITION:     Man,  age  53.     Prone.     Enema  method. 

ROENTGEN  CONCLUSIONS:     Marked  filling  defect  in  the  lower  portion  of  the  descending  colon. 

OPERATIVE  FINDINGS:      Inoperable  carcinoma  involving  the  descending  colon  and  sigmoid  with  perfora- 
tion into  the  bladder. 

A     Defect  due  to  growth. 
B     Rectum. 
C     Sigmoid. 


THE  ROEXTGEX   DIAGXOSIS   OF   SURGICAL  LESIONS 


259 


f 


FIGURE  336 


260  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


Figure  337 

PATIENT  —  POSITION:     Woman,  age  36.     Prone. 

ROENTGEN  CONCLUSIONS:     Small  annular  carcinoma  of  descending  colon. 

OPERATIVE  FINDINGS:     Small  annular  carcinoma  of  descending  colon. 

A  Approximate  size  of  the  annular  carcinoma. 

B  Transverse  colon. 

C  Filling  defect  in  caecum  which  at  operation  was  found  to  be  carcinoma. 

D  Large  normal  appendix. 

Figure  338 

PATIENT  — POSITION:     Woman,  age  69.     Prone. 

ROENTGEN  CONCLUSIONS:     Extensive  carcinoma  at  descending  colon  with  metastases  of  the  caecum. 

OPERATIVE  FINDINGS:     Extensive  involvement  of   the  descending  colon.     Secondary    involvement  of 
other  parts  of  the  large  bowel. 

A — B    Extent  of  growth  in  descending  colon. 

C    Annular  carcinoma  of  caecum. 

It  is  interesting  to  note  the  marked  atony  of  the  large  bowel. 


Figure  339 

Artist's  drawing  of  Case  338.     See  colored  Plate  V, 


PLATE  V  — FIGURE  339 

EXTENSIVE    CARCINOMA    OF    DESCENDING    COLON 


THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


261 


FIGURE  337 


FIGURE  338 


262  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  341 

PATIENT  — POSITION:     Man,  age  33.     Prone.     (Twenty-four  hour  plate.) 

ROENTGEN  CONCLUSIONS:     Small  annular  new  growth  of  sigmoid. 

OPERATIVE  FINDINGS:     Small  annular  new  growth  of  sigmoid.     Pathological  report,  adenocarcinoma. 

A — B     Extent  of  carcinoma. 


Figure  342 

Artist's  drawing  of  Figure  341  made  of  the  resected  portion. 

The  sigmoid  and  descending  colon  show  a  small  annular  carcinoma. 

The  Roentgen  plate  is  even  more  striking  than  the  resected  portion  of  the  colon. 


THE   ROEXTGEX   DIAGXOSIS   OF   SURGICAL   LESIONS 


263 


FIGURE  341 


FIGURE  342 


264  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  343 

PATIENT  — POSITION:     Woman,  age  48.     Prone. 

ROENTGEN  CONCLUSIONS:     New  growth  of  the  sigmoid  and  descending  colon. 

OPERATIVE  FINDINGS:     Annular  new  growth  of  sigmoid. 

A     Filling  defect  due  to  involvement  of  bowel  at  this  point. 


Figure  344 

PATIENT  —  POSITION:     Man,  age  31.     Prone. 

ROENTGEN  CONCLUSIONS:     Extensive  involvement  of  the  sigmoid. 

OPERATIVE  FINDINGS:     Extensive  involvement  of  the  entire  sigmoid.     Probable  carcinoma. 

A     Lower  boundary  of  bowel. 

B    Extension  of  growth  in  sigmoid. 

C    Point  of  marked  obstruction  about  the  descending  colon. 

This  is  a  forty-eight  hour  plate  and  shows  the  obstruction  at  point  C. 

An  enema  given  showed  the  obstruction  as  in  A  and  B. 

The  surgeon  also  considered  the  possibihty  of  the  growth  being  sarcoma  but  its  character  could  not 

be  definitely  proven  as  no  specimen  was  removed.     Patient  died  within  six  months. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS 


265 


FIGURE  343 


FIGURE  344 


266  THE   ROENTGEN   DIAGNOSIS  OF   SURGICAL  LESIONS 


Figure  345 

PATIENT  — POSITION:     Man,  age  61.     Prone.     Enema. 

ROENTGEN  CONCLUSIONS:     Extensive  new  growth  of  descending  colon,  sigmoid  and  rectum. 

OPERATIVE  FINDINGS:     Complete  involvement  of  whole  pelvic  cavity.     Carcinoma. 

A     Descending  colon. 

B     Rectum. 

C     Sigmoid.      The  only  portion  of  the  lower  bowel  that  is  normal. 


Figure  346 

PATIENT  — POSITION:  Woman,  age  28.  Prone.  Enema. 
ROENTGEN  CONCLUSIONS:  Obstruction  of  lower  bowel. 
OPERATIVE  FINDINGS:     Small  annular  carcinoma  of  descending  bowel. 

A     Point  of  obstruction. 
B     Dilated  sigmoid. 
C     Rectum. 


THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


267 


FIGURE  345 


FIGURE  346 


268  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


Figure  347 

PATIENT      POSITION:     Man,  age  58.     Prone.     Enema. 

ROENTGEN    CONCLUSIONS:     Diverticulitis  of  sigmoid  and   descending  colon,  with    possible  early  car- 
cinoma of  sigmoid. 
OPERATIVE  FINDINGS:     Small  annular  carcinoma.     Diverticulitis. 

A    Small  filling  defect  of  lower  bowel  due  as  it  proved  to  annular  carcinoma. 


THE   ROENTGEN   DIAGNOSIS   OF  SURGICAL   LESIONS  269 


FIGURE  347 


THE  ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS  271 


SECTION  IX 

DIVERTICULITIS  OF  THE  COLON 

^Multiple  diverticula  of  tlie  colon  are  not  so  uncommon  as  has  been  thought.  Their 
recognition  has  become  more  frequent  through  the  aid  of  the  Roentgen  ray.  In  our  ex- 
perience the  number  of  cases  of  diverticulitis  compared  with  the  cases  of  colonic  new  growth 
is  about  one  to  three. 

The  Roentgen  picture  of  multiple  diverticula  is  rather  characteristic.  After  the  passage 
of  the  bismuth  meal  we  may  find,  in  the  region  of  the  sigmoid  or  lower  descending  colon, 
numerous  discrete,  round  shadows  about  the  size  of  a  pea.  These  shadows  are  due  to 
portions  of  the  bismuth  meal  remaining  in  small  sacculations  in  the  gut. 

Under  the  Roentgenoscopic  screen,  these  shadows  are  seen  to  occur  in  groups  and 
to  bear  a  constant  relation  to  each  other.  jNIanipulation  may  show  the  relation  of  these 
shadows  to  the  wall  of  the  colon.  In  some  cases  there  will  be  found  a  definite  palpable  mass 
on  the  left  lower  quadrant,  due  to  a  peridiverticulitis  with  its  mass  of  inflammatory  tissue. 
This  picture  may  be  confused  with  new  growth  of  the  colon,  and  it  may  be  suggested 
that  there  is  a  casual  relation  between  this  condition  and  new  growth. 

The  important  diagnostic  factor  is  the  prolonged  retention  of  the  bismuth  in  the  di- 
verticula. It  is  not  uncommon  to  find  these  shadows  persisting  for  four  or  five  days  after 
the  bismuth  meal.  Case  reports  one  case  where  the  diverticula  retained  bismuth  on  the 
sixteenth  day. 

The  diagnosis  may  sometimes  be  made  -ndth  the  bismuth  enema.  The  patient  should 
be  encouraged  to  retain  the  enema  as  long  as  possible.  It  is  also  advisable  to  have  a  higher 
percentage  of  barium  in  the  solution.  The  patient  should  be  examined  just  previous  to 
expelling  the  solution  and  thirty  to  sixty  minutes  afterwards.  This  usually  insures  proper 
filling  of  the  diverticula.  It  will  frequently  be  noted  that  these  patients  will  not  be  able 
to  empty  the  whole  colon,  usually  only  the  rectum  and  lower  sigmoid. 

A  careful  series  of  plates  must  be  made  in  suspected  cases  of  colonic  new  growth  even 
though  miiltiple  diverticula  be  present.  In  the  writers'  experience  early  carcinoma  may  have 
its  beginning  in  these  areas  and  unless  extreme  care  is  exercised,  one  may  overlook  early  new 
growth.  The  problem  is  parallel  to  the  recognition  of  early  gastric  cancer  beginning  on 
chronic  ulcer. 

A  very  good  rule  to  observe,  in  the  presence  of  diverticula  of  the  bowel,  is  to  consider  new 
growth  if  there  is  found  a  narrowing  of  the  lumen  of  the  bowel  at  any  point.  DiverticuUtis 
will  not  cause  a  localized  stenosis  as  in  Figure  347, 


272  THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


DIVERTICULITIS 

Figure  348 

PATIENT  — POSITION:     Woman,  age  48.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Diverticulitis. 
OPERATIVE  FINDINGS:     No  operation. 

A    Sigmoid. 

B     Splenic  flexure. 

Figure  349 

PATIENT  —  POSITION:     Man,  age  46.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Diverticulitis. 
OPERATIVE  FINDINGS:     Diverticulitis. 

A — B    Multiple  diverticula. 

Figure  350 

PATIENT  — POSITION:     Woman,  age  44.     Prone. 
ROENTGEN  CONCLUSIONS:     Diverticulitis. 
OPERATIVE  FINDINGS:     Diverticulitis. 

A — B     Multiple  diverticula. 


Figure  351 


PATIENT  —  POSITION:     Man,  age  52.     Prone. 
ROENTGEN  CONCLUSIONS:      Diverticulitis. 
OPERATIVE  FINDINGS:     No  operation. 

A — B     Multiple  diverticula. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL  LESIONS 


273 


FIGURE  348 


FIGURE  349 


FIGURE  350 


FIGURE   351 


274  THE   ROENTGEN   DIAGNOSIS   OF   SURGICAL   LESIONS 


Figure  352 

PATIENT  — POSITION:     Woman,  age  46.     Prone. 

ROENTGEN  CONCLUSIONS:     Diverticulitis  of  sigmoid  and  descending  colon. 

OPERATIVE  FINDINGS:     Several  diverticula  removed  from  the  lower  bowel. 

A — B     Large  diverticula. 


Figure  353 

Artist's  drawing  of  Case  352.    See  colored  insert,  Plate  VI. 


Figure  354 

PATIENT  —  POSITION:     Woman,  age  48.     Prone.     Enema. 
ROENTGEN  CONCLUSIONS:     Diverticulitis  of  the  lower  colon. 
OPERATIVE  FINDINGS:     Several  large  diverticula  removed. 

A     Several  large  diverticula. 


Figure  355 

PATIENT  —  POSITION:     Man,   age  63.     Prone.      (Twenty-four  hour  plate.) 
ROENTGEN   CONCLUSIONS:     Diverticulitis  of  the  entire  colon. 
OPERATIVE  FINDINGS:     No  operation. 

A — B     Area  of  diverticula  of  lower  bowel. 


>. 


y 


PLATE  VI  — FIGURE  353 

DIVERTICULITIS    OF    DESCENDING   COLON 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


275 


FIGURE  354 


FK3URE  355 


276  THE  ROENTGEN  DIAGNOSIS  OF  SURGICAL  LESIONS 


Figure  356 

PATIENT  —  POSITION:     Woman,  age  63.     Prone.     (Twenty-four  hour  plate.) 
ROENTGEN  CONCLUSIONS:     Diverticulitis  of  the  whole  colon. 
OPERATIVE  FINDINGS:     No  operation. 

A — B     Multiple  diverticula. 

C    Appendix. 

D     Diverticula  in  transverse  colon. 


Figure  357 

PATIENT  —  POSITION:     Man,  age  58.     Prone.     Enema  method. 
ROENTGEN  CONCLUSIONS:     Diverticulitis. 
OPERATIVE  FINDINGS:     No  operation. 

A — B     Diverticulitis  of  sigmoid  and  descending  colon. 
C     A  small  diverticulum. 
D    Gall-stones. 


THE  ROENTGEN  DIAGNOSIS   OF  SURGICAL   LESIONS 


277 


FIGURE  357 


278  THE  ROENTGEN   DIAGNOSIS   OF  SURGICAL  LESIONS 


ROENTGEN  TERMS 

At  a  meeting  of  the  American  Roentgen  Ray  Society,  October  1,  1913,  on  the  recom- 
mendation  of  the   Committee  on  Nomenclature,   the   Society  adopted  the  following  terms: 

Roentgen:  To  be  pronounced  rent-gen. 

Roentgen  ray:  A  ray  discovered  and  described  by  Wilhelm  Komad  Roentgen. 

Roentgenology:  The  study  and  practice  of  the  Roentgen  ray  as  apphed  to  medical 
science. 

Roentgenologist:  One  skilled  in  Roentgenology. 

Roentgenogram:  The  shadow  picture  produced  by  the  Roentgen  ray  on  a  sensitive 
plate  or  film. 

Roentgenograph  (verb):  To  make  a  Roentgenogram. 

Roentgenoscope  :  An  apparatus  for  examination  with  the  fluorescent  screen  excited 
by  the  Roentgen  ray. 

Roentgenoscopy:  Examination  by  means  of  the  Roentgenoscope. 

Roentgenography:  The  art  of  making  Roentgenograms. 

Roentgenize:  To  apply  the  Roentgen  ray. 

RoENTGENizATiON :  Apphcation  of  the  Roentgen  ray. 

Roentgenism:  Untoward  effect  of  the  Roentgen  ray. 

Roentgen  diagnosis,  Roentgen  therapy,  Roentgen  dermatitis:  These  terms  are 
self-explanatory. 


INDEX 


Adhesions,  intestinal,  pp.  226-249,  Figs.  296-324.     See  also  under 
appendix,  colon,  duodenum,  gall-bladder,  ileum,  intestine 
(large  and  small),  stomach. 
Adhesions,  multiple,  Figs.  163,  168,  170,  171,  205,  216,  297,  319. 

Pelvic,  Fig.  245. 
Apparatus,  p.  3. 

Appendix,  pp.  188-220,  Figs.  248-295. 
Acute,  p.  189. 
Adhesions,  Figs.  253,  255,  261,  262,  264,  269,  278,  281,  285, 

286,  293. 
Adhesions,  diagnosis  of,  p.  190. 
Chronic,  p.  190,  Figs.  23,  28,  31,  225-227,  230,  231,  239,  240, 

249-295,  300,  309A,  310,  317,  320,  323. 
Concretions  in,  p.  190,  Figs.  251,  259,  286,  288,  290. 
Diagnosis,  p.  189. 
Kinked,  Figs.  250,  257-259,  262,  265,  267,  270,  271,  273-276, 

278,  280,  283,  292,  294. 
Long,  Fig.  292. 

Obliterated,  Figs.  249,  252,  257,  263. 
Retrocecal,  Figs.  255,  259,  261,  266,  285,  287,  294,  303. 
Stasis  in,  p.  190. 
Technique,  p.  188. 
Test  meal  for,  p.  188. 

Bile  in  cystic  duct.  Fig.  184. 
Bladder,  dilated,  Fig.  246. 

Cajcum,  adhesions.  Figs.  298,  300,  314. 

Deformity  caused  by  adhesions.  Figs.  294,  307. 

Dilatation,  Figs.  300,  309,  331. 

Kinking,  Fig.  304. 

Tuberculosis  of.  Figs.  237,  243,  298. 

Tumors  of,  Figs.  326,  327. 
Calculi,  biliary.     See  gall-stones. 

Renal,  p.  143. 
Cancer,  pp.  35,  68.  See  also  under  colon,  duodenimi,  gall-bladder, 
ileum,  intestines,  jejimum,  liver,  oesophagus,  rectum,  sig- 
moid, stomach. 

Early,  diagnosis  of,  p.  68. 
Cardia,  ulcer  at.  Fig.  165. 
Cardio-spasm,  Fig.  36. 

Cholecystitis,  p.  143,  Figs.  21,  25,  27,  199,  200,  213. 
Cholesterine  gall-stones,  p.  142,  Figs.  187,  193. 
Colitis,  p.  225,  Fig.  300. 

Colon,  adhesions,  p.  224,  Figs.  222,  227,  239,  253,  260,  269,  291, 
297-301,  304-312,  314,  318,  319,  321-323. 

Cancer,  Figs.  328,  329,  335,  337,  338,  340,  345. 

Diverticuhtis  of,  pp.  271-277,  Figs.  347-357. 

Enema  for  examination  of,  p.  222. 

Malformation  and  malposition,  p.  224. 

Obstruction  and  stenosis,  Figs.  311A,  312,  316,  321,  331. 

Ptosis,  Fig.  11. 

Tuberculosis,  Fig.  298. 

Tumors,  p.  223,  Figs.  328-340,  345. 
Constipation,  chi-onic,  p.  223. 
Cystic  duct,  bile  in.  Fig.  184. 

Diagnosis  between  gastric  lesion  and  pressure  of  large  intestine. 
Fig.  33. 

Direct,  p.  2. 

Indirect,  p.  1. 
Diverticulitis,  p.  271,  Figs.  347-357. 


Diverticulum,  p.  95,  Figs.  235,  236,  238,  348-357. 
Duodenal  cap,  p.  96. 
Duodenum,  pp.  92-139. 

Adhesions,  Figs.  168-171,  182.     See  also  under  ulcer,  duo- 
denal and  adhesions. 

Anatomical  variation.  Figs.  2,  220. 

Cancer,  Fig.  181. 

Dilatation,  Figs.  68,  168,  297. 

Diverticulum,  p.  95. 

Gall-bladder  perforating  into.  Fig.  141. 

Normal,  p.  93,  Fig.  122. 

Obhteration  due  to  ulcer.  Figs.  138,  140,  145,  146,  148,  155, 
157,  166,  167. 

Obstruction  caused  by  tumor.  Figs.  177-180. 

Technique,  p.  93. 

Ulcer,  p.  92.     See  ulcer,  duodenal. 

Enema  for  intestinal  examination,  p.  222. 

GaU-bladder,  pp.  140-165,  Figs.  182-219. 

Adhesions,  Figs.  139,  168,  172,  174,  182,  216,  281,  307. 

Cancer,  Fig.  329. 

Disease  of,  p.  143,  Figs.  21,25,  27,  199,200,  205,213,  216,  307. 

Identification  of,  p.  142. 

Perforating  into  duodenum.  Fig.  141. 

Pressing  on  duodenum.  Fig.  205. 
GaU-stones,  pp.  140-165,  Figs.  141,  182-219,  306. 

Composition  of,  p.  142. 

Diagnosis  of,  p.  142. 

Differentiating  from  other  conditions,  p.  141. 

In  common  duct,  Fig.  199. 

In  cystic  duct.  Fig.  189A. 

Interpretation  of  plates,  p.  142. 

Mistaken  for  appendicitis.  Fig.  189A. 

Mistaken  for  stone  in  the  kidney,  Fig.  208. 

Multiple,  Figs.  184,  186,  189A,  195,  200,  201,  209,  210,  212, 
213,  215. 

Percentage  shown  bj'  Roentgen  rays,  p.  140. 

Technique,  p.  140. 
Gastro-intestinal  diagnosis,  p.  1. 

Haudek's  niche,  p.  95. 
Hepatic  flexure,  tumors  at,  Figs.  328,  329. 
Hernia,  p.  166. 

Hirschprung's  disease.  Fig.  313. 

Hour-glass  stomach,  pp.  34,  70,  Figs.  39,  41,  42,  44,  45,  53,  54-56, 
60,  61,  63,  83,  165. 

Double,  Fig.  166. 

Due  to  cancer,  p.  70,  Fig.  110. 
HypermotiUty  of  stomach,  p.  96. 
Hypernephroma,  Figs.  34,  35. 
Hyperperistalsis,  p.  95. 

Ileal  stasis,  p.  167,  Figs.  222,  223,  225,  227,  231,  239,  241-243. 
IleocEecal  valve,  incompetency  of.  Figs.  297,  298,  311,  323. 
Ileum,  adhesions.  Figs.  240,  241,  245. 

Cancer,  Fig.  234. 

Dilatation,  Figs.  222,  223,  230,  231,  244,  327,  331. 

Displacement,  Figs.  245,  246,  247. 

Normal,  p.  166,  Fig.  220A. 

Obstruction  of.  Figs.  228,  229,  234,  314. 


279 


280 


INDEX 


Intestine,  large,  pp.  222-277,  Figs.  296-357. 

Adhesions,  pp.  224,  226-249,  Figs.  222,  227,  239,  253,  260, 

269,  291,  294,  296-324. 
Congenital  dilatation.  Fig.  313. 
Enema  for,  p.  222. 

Malformation  and  malposition,  p.  224. 
Method  of  study,  p.  222. 
Normal  appearance,  p.  222,  Figs.  226,  248. 
Obstruction  due  to  liver  abscess,  Fig.  312. 
Tuberculosis  of.  Figs.  237,  243,  298. 
Tumors,  pp.  223,  250-269,  Figs.  325-347. 
Intestine,  small,  pp.  166-186,  Figs.  220-247. 

Adhesions,  p.  167,  Figs.  221,  222,  225,  229,  231,  240,  241,  244, 

245.     See  also  under  duodenun,  adhesions. 
Cancer,  Figs.  224,  234. 
Diagnosis,  p.  166. 

Diverticulum  of.  Figs.  235,  236,  238. 
Passage  of  bismuth  through,  p.  166. 
Tumors,  p.  167,  Figs.  177-180.     See  also  under  ileum,  cancer 

and  jejunum,  cancer. 
Intestines,  cancer.  Figs.  181,  224,  234,  326,  328,  329,  335,  336-338, 

340,  341,  344-347. 
Tuberculosis,  Figs.  237,  243,  298. 

Jackson's  membrane.  Fig.  303. 
Jejunum,  cancer,  Fig.  224. 

Dilatation  and  obstruction  of.  Figs.  221,  224. 

Diverticulum  of.  Figs.  235,  236,  238. 

Normal,  p.  166,  Fig.  220A. 

Ulcer,  p.  167. 

Kidney,  stone  in  the,  p.  143. 
Tumors,  Figs.  34,  35. 

Lane's  kink,  p.  167,  Figs.  28,  222,  223,  226,  227,  233,  244,  276. 
Liver,  abscess,  causing  intestinal  obstruction,  Fig.  312. 

Adhesions,  Figs.  168,  216. 

Cancer,  Fig.  329. 

Meal,  bismuth-buttermilk,  p.  2. 

Bismuth-cereal,  p.  2. 

Opaque  enema,  p.  222. 
Membranes. 
Mucosal  defect  of  duodenum,  p.  94. 

ffisophagus,  cancer.  Fig.  95. 

Dilatation  in  an  infant.  Figs.  177-180. 

Obstruction  of.  Fig.  36. 
Omentum,  adhesions.  Fig.  318. 

Pancreas  and  gastric  ulcer.  Fig.  50. 

Pericohc  membrane.  Figs.  242,  253,  260,  301,  305,  309,  310,  317, 

320,  322. 
Pericolitis,  Figs.  300,  303. 
Peritonitis,  old.  Fig.  229. 

Tubercular,  Figs.  230,  316. 
Prognathion  dilatation.  Fig.  76. 
Ptosis,  Figs.  9,  11,  14,  15,  16,  19,  22,  33. 
Pylorus,  cancer,  p.  35,  Figs.  92-96. 

Contraction,  normal.  Fig.  27. 

Obstruction  of.  Fig.  34. 

Spasm,  p.  35. 

Ulcer  at,  Figs.  69,  71,  73,  74,  76,  77,  79,  83A. 


Rectum,  cancer.  Figs.  345,  346. 
Reider  test  meal,  p.  2. 
Retroperitoneal  tumors.  Fig.  35. 
Roentgenoscopy,  pp.  1,  32,  96. 

Sigmoid,  adhesions.  Fig.  323. 

Cancer,  Figs.  336,  340,  341,  344-347. 

DiverticuHtis  of.  Figs.  347,  352,  357. 

Tumors  of.  Figs.  343,  344. 
Sphincter,  pyloric.  Fig.  27. 
Spine,  pressure  on  stomach,  Fig.  7. 
Stereoscopy  in  gall-stone  work,  p.  141. 
Stomach,  pp.  1-91. 

Adhesions,  Figs.  45,  55-57,  65. 

Anatomical  variation.  Figs.  2,  220. 

Cancer,  pp.  35,  68,  Figs.  86-121. 

Dilatation  of.  Figs.  9,  14,  15,  16,  19,  21,  29,  30,  33. 

Dilatation  in  an  infant.  Figs.  177-180. 

Hour-glass,  p.  34.     See  hour-glass  stomach. 

Hypermotility  in  duodenal  ulcer,  p.  96. 

Normal,  pp.  1-31,  Figs.  1-33. 

Ptosis  of.  Figs.  9,  14-16,  19,  22,  33. 

Redundancy  of  mucous  membrane.  Fig.  48. 

Resection,  Fig.  75. 

Shape  of,  p.  4. 

Spasm  of,  p.  35. 

Tumors  of,  pp.  34,  68-91,  Figs.  67,  84-121. 

Tumors  of,  diagnosis,  p.  68. 

Ulcer  of,  p.  32.     See  ulcer,  gastric. 

Technique,  general,  p.  3. 

Tuberculosis.     See  caecum,  colon,  intestines,  peritonitis. 
Tumors.     See  cancer,  intestines,  kidney,  stomach. 
Intra-abdominal,  p.  166. 

Ulcer,  duodenal,  pp.  92-139,  Figs.  53,  56,  58,  62,  71,  125-174. 

And  adhesions,   p.  94,  Figs.  136,  139,  141,  145,  147,  148, 
155,  157,  166-172. 

And  gastric  hyperperistalsis,  p.  95. 

Diagnosis  of,  p.  92. 

Hypermotility  of  stomach  in,  p.  96. 

Obstructive  type,  Figs.  138,   140,   145,   146,   148,   155,  157, 
166,  167. 

Perforating,  Figs.  143,  162. 

Pinpoint  defect  of  mucosa,  p.  94,  Figs.  144,  147,  153,  160, 
173. 
Ulcer,  gastric,  pp.  32-67,  Figs.  36-83A,  165,  182. 

Acute,  Fig.  79. 

Diagnosis  of,  pp.  33,  35. 

Disproved  by  Roentgen  rays.  Fig.  159. 

Induration  in,  p.  34. 

Mahgnant,  Figs.  87-91,  93,  104,  114,  115. 

Malignant  degeneration  of,  p.  69. 

Perforating,  p.  33,  Figs.  39,  41,  43,  44,  49,  50,  71. 

Technique,  p.  32. 
Ulcer,  jejunal,  p.  167. 
Uterus,  gravid.  Fig.  247. 

Valvulie  conniventes,  Fig.  1. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RD  540  G29  Q  C.2 

The  Roi'"iij"i:  i;  .^q-.o'y,  u'  -.umical  lesio 


"ERSITY  TTPRAPTES 

■  indicF 


DATE  DUE 



Demco,  Inc.  38-293 


